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  1. psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
    October 01, 2011 - SPOTLIGHT CASE Abdominal Aortic Aneurysm Screening Citation Text: Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX E…
  2. psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
    November 01, 2012 - Defensive Medicine: "Glowing" with Pain Citation Text: Sethi MK. Defensive Medicine: "Glowing" with Pain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49848/psn-pdf
    January 01, 2019 - Inadequate Preanesthetic Evaluation, Airway Trouble November 1, 2018 Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble The Case Case #1: A 34-year-old woman was scheduled for a hysteroscopy under g…
  4. psnet.ahrq.gov/web-mm/after-visit-confusion
    August 21, 2007 - After-Visit Confusion Citation Text: Ventres W. After-Visit Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
  5. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.335_slideshow.ppt
    December 01, 2014 - PowerPoint Presentation Spotlight A Stroke of Error This presentation is based on the December 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Kevin M. Barrett, MD, MSc, Consultant, Associate Professor of Neurology, Director, Neurohospitalist F…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49524/psn-pdf
    November 01, 2006 - Secured But Not Always Safe November 1, 2006 Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/secured-not-always-safe The Case An 84-year-old healthy woman underwent an elective left total knee replacement for degenerative osteoarthritis. She received spinal …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73905/psn-pdf
    October 06, 2021 - Health Equity and Maternal Health October 6, 2021 Tully K, Stuebe AM, Gibson A, et al. Health Equity and Maternal Health. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/health-equity-and-maternal-health Redefining Maternal Safety Maternal safety refers to the safety of a person during pregnancy, childb…
  8. psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
    August 01, 2006 - Tacit Handover, Overt Mishap Citation Text: Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
  9. psnet.ahrq.gov/web-mm/too-tight-control
    March 20, 2013 - SPOTLIGHT CASE Too Tight Control Citation Text: Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837659/psn-pdf
    July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging July 8, 2022 Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging The Cases Case #1: A 42-year-old woman admitted with…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33801/psn-pdf
    February 01, 2016 - In Conversation With…Christine A. Sinsky, MD February 1, 2016 In Conversation With…Christine A. Sinsky, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md Editor's note: Christine A. Sinsky, MD, is the Vice President for Professional Satisfaction at the American Me…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49828/psn-pdf
    May 01, 2018 - Out of Sight, Out of Mind: Out-of-Office Test Result Management May 1, 2018 Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management Case Objectives Recognize the general responsibilities of…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49819/psn-pdf
    February 01, 2018 - Signout Fallout February 1, 2018 Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/signout-fallout Case Objectives Understand the role of communication failures in medical errors and preventable adverse events. Review the evidence in support of handoff improvement pr…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60745/psn-pdf
    October 01, 2020 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia July 29, 2020 Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/multiple-high-risk-events-involvi…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49549/psn-pdf
    December 06, 2007 - Elopement December 1, 2007 Gerardi D. Elopement. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/elopement Case Objectives Define elopement and differentiate it from wandering and leaving against medical advice. Identify leading contributors to elopement events. Describe strategies for preventing elopement…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33702/psn-pdf
    November 01, 2010 - In Conversation with...Patrick S. Romano, MD, MPH November 1, 2010 In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph Editor's note: Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the Universit…
  17. psnet.ahrq.gov/web-mm/ecg-not-normal
    November 10, 2015 - SPOTLIGHT CASE The ECG Is Not Normal Citation Text: Zuger A. The ECG Is Not Normal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
  18. psnet.ahrq.gov/web-mm/right-left-neither
    November 16, 2022 - SPOTLIGHT CASE Right? Left? Neither! Citation Text: Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…
  19. psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
    March 01, 2019 - In Conversation With… Susan Haas, MD, MSc March 1, 2019  Also Read an Essay Citation Text: In Conversation With… Susan Haas, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. …
  20. psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
    September 27, 2023 - SPOTLIGHT CASE Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations Citation Text: Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

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