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psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
August 21, 2024 - Doctor, Don't Treat Thyself
Citation Text:
Rosvold EO. Doctor, Don't Treat Thyself. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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effectivehealthcare.ahrq.gov/sites/default/files/carman-presentation.pdf
May 29, 2025 - Carman-notes-151021 copy-Teresa
We got invited to submit a publication to Health Affairs in 2013 that really asked us to
think, “How do we think about patient and
family engagement? How can
we think about
what are the major issues in
this area?” We've been
thinking about this concept for a long
time, …
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psnet.ahrq.gov/web-mm/harm-alarm-fatigue
February 14, 2018 - SPOTLIGHT CASE
Harm From Alarm Fatigue
Citation Text:
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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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.
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psnet.ahrq.gov/web-mm/perils-contrast-media
March 01, 2007 - SPOTLIGHT CASE
The Perils of Contrast Media
Citation Text:
Sadat U, Solomon R. The Perils of Contrast Media. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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datatools.ahrq.gov/nhqdr/resources-addressing-disparities-and-improving-quality/
January 01, 2022 - Skip to main content
An official website of the Department of Health and Human Services
Search All AHRQ Sites
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Us
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psnet.ahrq.gov/node/49705/psn-pdf
January 01, 2020 - A "Reflexive" Diagnosis in Primary Care
April 1, 2014
Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
Case Objectives
Appreciate that primary care doctors may be caring for an increasing number of patients wi…
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psnet.ahrq.gov/node/838855/psn-pdf
October 27, 2022 - False Assumptions Result in a Missed Pneumothorax
after Bronchoscopy with Transbronchial Biopsy.
October 27, 2022
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy
with Transbronchial Biopsy. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/false-assumptions-resul…
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psnet.ahrq.gov/node/61078/psn-pdf
October 28, 2020 - Inpatient Stroke Management in an Adolescent with Type
1 Diabetes and Home Insulin Pump
October 28, 2020
Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1
Diabetes and Home Insulin Pump . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/inpatient-stroke-management…
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psnet.ahrq.gov/web-mm/ounce-prevention
February 17, 2011 - SPOTLIGHT CASE
An Ounce of Prevention
Citation Text:
Kucher N. An Ounce of Prevention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
January 01, 2019 - Spotlight
Spotlight
Mistaken Attribution, Diagnostic Misstep
*
Source and Credits
This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD
…
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psnet.ahrq.gov/node/49699/psn-pdf
February 01, 2014 - Multifactorial Medication Mishap
February 1, 2014
Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
Case Objectives
Understand the system-based causes of medication errors.
Describe a model for a systems approach to error analysis.
Id…
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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication
Breakdown.
August 30, 2023
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
Disclosure of Relevant Financial Relationship…
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - Spotlight
Spotlight
Prolonged DKA in Pregnancy: A Case of Communication
Breakdown
Source and Credits
• This presentation is based on the August 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarah Marshall, MD and Nina M. …
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psnet.ahrq.gov/web-mm/breakage-picc-line
June 21, 2023 - SPOTLIGHT CASE
Breakage of a PICC Line
Citation Text:
Dimov V. Breakage of a PICC Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/47565/psn-pdf
April 27, 2019 - Unintentionally retained foreign objects: a descriptive
study of 308 sentinel events and contributing factors.
April 27, 2019
Steelman VM, Shaw C, Shine L, et al. Unintentionally Retained Foreign Objects: A Descriptive Study of
308 Sentinel Events and Contributing Factors. Jt Comm J Qual Patient Saf. 2019;45(4):249…
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psnet.ahrq.gov/node/841761/psn-pdf
December 21, 2022 - Are the World Health Organization's patient safety
learning objectives still up-to-date: a group concept
mapping study.
December 21, 2022
Vogt L, Stoyanov S, Bergs J, et al. Are the World Health Organization's patient safety learning objectives
still up-to-date: a group concept mapping study. J Patient Saf. 2022;1…
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cds.ahrq.gov/sites/default/files/cds/artifact/106/HWI_2017.pptx
January 01, 2017 - Objective
Evaluate the impact of multiple interventions on appropriate obesity documentation and on adherence
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psnet.ahrq.gov/node/46849/psn-pdf
May 23, 2018 - 1,300 days and counting: a risk model approach to
preventing retained foreign objects (RFOs).
May 23, 2018
Duggan EG, Fernandez J, Saulan MM, et al. 1,300 Days and Counting: A Risk Model Approach to
Preventing Retained Foreign Objects (RFOs). Jt Comm J Qual Patient Saf. 2018;44(5):260-269.
doi:10.1016/j.jcjq.2017.…
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psnet.ahrq.gov/node/42693/psn-pdf
December 23, 2016 - Preventing unintended retained foreign objects.
December 23, 2016
Preventing unintended retained foreign objects. Sentinel event alert. 2013;(51):1-5.
https://psnet.ahrq.gov/issue/preventing-unintended-retained-foreign-objects
Sentinel event alerts are issued periodically by The Joint Commission to identify common …