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  1. psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
    December 01, 2014 - Serious or fatal iatrogenic complications occur in 2.9% to 3.7% of hospitalized patients ( 1 ), and medical
  2. psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx Spotlight Premature Closure: Was it Just Syncope? Source and Credits • This presentation is based on the November 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit i…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49670/psn-pdf
    November 01, 2012 - Missed Pneumonia November 1, 2012 Rohde JM, Flanders S. Missed Pneumonia. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/missed-pneumonia The Case A 32-year-old man presented to the emergency department (ED) with 3 days of fever and right pleuritic chest pain. Review of systems was negative for cough or dy…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846125/psn-pdf
    March 15, 2023 - The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis March 15, 2023 https://psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels- and-effective Summary …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49472/psn-pdf
    March 01, 2005 - Preventable Rash March 1, 2005 McLean C. Preventable Rash. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/preventable-rash The Case A 35-year-old man with HIV was being followed in an outpatient internal medicine clinic. At a routine visit, screening laboratories were checked. The clinic never contacted th…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49569/psn-pdf
    September 01, 2008 - Where's the Feeding Tube? September 1, 2008 Metheny NA, Meert KL. Where's the Feeding Tube? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/wheres-feeding-tube The Case A 13-year-old boy was involved in a motor vehicle collision and experienced a traumatic brain injury. Because of the injuries, he was unabl…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49517/psn-pdf
    August 01, 2006 - Miscalculated Risk August 1, 2006 Strassels SA. Miscalculated Risk. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/miscalculated-risk The Case A healthy 36-year-old man was admitted to a teaching hospital for acute low back strain after lifting his 2- week-old infant. He received Vicodin (hydrocodone and a…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49423/psn-pdf
    November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33847/psn-pdf
    August 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS August 1, 2017 In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0 Editor's note: Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwest…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33685/psn-pdf
    May 01, 2009 - In Conversation with…William B. Weeks, MD, MBA May 1, 2009 In Conversation with…William B. Weeks, MD, MBA. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba Editor's note: William B. Weeks, MD, MBA, is Associate Professor of Psychiatry and of Community and Family M…
  11. psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
    January 01, 2020 - Spotlight Too Many Cooks in the Kitchen Source and Credits • This presentation is based on the August 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Richard P. Dutton, MD, MBA o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33786/psn-pdf
    May 01, 2015 - Video to Improve Patient Safety: Clinical and Educational Uses May 1, 2015 Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient Safety: Clinical and Educational Uses. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses Perspective Reports of…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49797/psn-pdf
    June 01, 2017 - Diagnostic Overshadowing Dangers June 1, 2017 Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers The Case A 72-year-old woman with history of opioid abuse was sent to the emergency department (ED) from a methadone clinic because she a…
  14. psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-disclosure
    February 26, 2025 - “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV) Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL June 30, 2021 Innovat…
  15. psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation
    March 27, 2024 - Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation Citation Text: Kulig CE, Ebong IA. Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation …
  16. psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
    November 03, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Diagnostic Errors Case Studies  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Maria Mirica, PRIDE Group …
  17. psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
    May 01, 2006 - Medication Reconciliation Pitfalls Citation Text: Weber RJ. Medication Reconciliation Pitfalls. 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…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845473/psn-pdf
    March 15, 2023 - Remote Patient Monitoring March 15, 2023 Hood C, Sikka N, Van CM, et al. Remote Patient Monitoring. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/remote-patient-monitoring Remote Patient Monitoring The delivery of healthcare through electronic communication, or telehealth, has changed greatly since it…
  19. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.308_slideshow.ppt
    October 01, 2013 - PowerPoint Presentation Spotlight Case It's Sarah, not Stephen! 1 This presentation is based on the October 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Urmimala Sarkar, MD, MPH, University of California at San Francisco Editor, AHRQ WebM&…
  20. psnet.ahrq.gov/web-mm/surprise-wire
    July 15, 2020 - Surprise Wire Citation Text: Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

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