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psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx
Spotlight
Delayed Diagnosis and Treatment of Systemic Lupus
Erythematosus with a Psychiatric Presentation
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full …
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psnet.ahrq.gov/node/49408/psn-pdf
July 01, 2003 - Check the Wristband
July 1, 2003
Rosenthal M. Check the Wristband. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/check-wristband
The Case
The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the
impending surgery. The patient spoke English and appeared to be of aver…
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psnet.ahrq.gov/node/850675/psn-pdf
June 14, 2023 - Patient and Family Roles in Safety
June 14, 2023
Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety
Moving From Engagement to Partnership
Involving patients and families in healthcare decisions about patient c…
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psnet.ahrq.gov/node/33637/psn-pdf
August 01, 2006 - In Conversation with...Lucian Leape, MD
August 1, 2006
In Conversation with..Lucian Leape, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: What kind of career did you fashion for yourself prior to
getting involved in safety an…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - PowerPoint Presentation
Spotlight
A Lot of Pain (Medications)
1
This presentation is based on the September 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Shoshana J. Herzig, MD, MPH, Division of General Medicine, Beth Israel Deaconess Medic…
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psnet.ahrq.gov/node/33839/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
Editor's note: Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of
Northwester…
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psnet.ahrq.gov/node/842923/psn-pdf
February 01, 2023 - Aspergillus Mediastinitis & Endocarditis in a Pediatric
Patient Complicating Cardiac Surgery and Bedside Chest
Closure.
February 1, 2023
Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient
Complicating Cardiac Surgery and Bedside Chest Closure. PSNet [internet]. …
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psnet.ahrq.gov/node/49573/psn-pdf
January 01, 2009 - Dangerous Shift
November 1, 2008
Patterson ES. Dangerous Shift. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/dangerous-shift
Case Objectives
Review the evidence base on erroneous actions related to shift changes.
Understand the limits of standardizing handoffs in preventing errors at shift change.
Expla…
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - Failure to Rescue the Mother
Citation Text:
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
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psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - SPOTLIGHT CASE
Missed Appendicitis
Citation Text:
Adams JG. Missed Appendicitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - In Conversation with...James L. Reinertsen, MD
August 1, 2007
In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting
firm …
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psnet.ahrq.gov/node/33865/psn-pdf
September 01, 2018 - In Conversation With… Rebecca Lawton, PhD
September 1, 2018
In Conversation With… Rebecca Lawton, PhD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
Editor's note: Rebecca Lawton, a Professor in the Psychology of Healthcare at the University of Leeds, is
a health psycho…
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psnet.ahrq.gov/innovations
February 26, 2025 - Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …
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psnet.ahrq.gov/curated-library/diagnostic-error
May 05, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Diagnostic Error
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Created By: Karen Cosby, AHRQ
Date Created: May 8, …
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psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention
July 23, 2024 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans
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May 31, 2023
Innovation
Contact
…
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psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
November 27, 2019 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities
Citation Text:
Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…
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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/periodic-issue/periodic-issue-469
December 31, 2024 - January 8, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports…
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psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
July 23, 2024 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care
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December 23, 2020
…
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psnet.ahrq.gov/primer/long-term-care-and-patient-safety
February 24, 2022 - Long-term Care and Patient Safety
Citation Text:
Bakerjian D. Long-term Care and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 …