- 
                                        
psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - The patient's pain continued, sometimes leaving her writhing on the floor, and was unrelieved by opioids
                                     
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
January 01, 2022 - • The patient's pain continued, sometimes leaving her writhing on the 
floor, and was unrelieved by opioids
                                     
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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - adjustments     Reduce or remove psychoactive drugs (e.g., anticholinergics, sedatives, or hypnotics, opioids
                                     
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psnet.ahrq.gov/node/49585/psn-pdf
May 01, 2009 - given to drugs that have recently been stopped and may cause a withdrawal syndrome (alcohol, chronic
opioids
                                     
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psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
January 07, 2022 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers 
 
 
 
 
 Citation Text: 
 Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic… 
                                     
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - Spotlight
Spotlight
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations 
1
Source and Credits
This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available 
Commentary by: Samantha Brown… 
                                     
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psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
October 01, 2016 - In Conversation With… Richard Platt, MD, MSc 
 October 1, 2016 
                       
 
 
 
 Also Read an Essay  
 
 
 
 
 
 
 
 
 
 Citation Text: 
 In Conversation With… Richard Platt, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. … 
                                     
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - given to drugs that have recently been stopped and may cause a withdrawal syndrome (alcohol, chronic opioids
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - The patient's pain continued, sometimes leaving her writhing on the floor, and was unrelieved by opioids
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/33602/psn-pdf
March 15, 2025 - Individual Clinician Performance Issues
March 15, 2025
Individual Clinician Performance Issues. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/individual-clinician-performance-issues
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current res… 
                                     
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psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
January 01, 2014 - Annual Perspective 
 
 
 Computerized Provider Order Entry and Patient Safety 
 Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015 
                       
 
 
 
 
 
 
 View more articles from the same authors. 
 
 
 
 
 
 
 Citation Text: 
 Sarkar U, Shojania KG. Computerized Provider Order Entry and Patien… 
                                     
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psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
December 22, 2018 - Annual Perspective 
 
 
 Burnout Among Health Professionals and Its Effect on Patient Safety 
 Audrey Lyndon, PhD | January 1, 2015 
                       
 
 
 
 
 
 
 View more articles from the same authors. 
 
 
 
 
 
 
 Citation Text: 
 Lyndon A. Burnout Among Health Professionals and Its Effect on Patient Safety… 
                                     
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - WebM&M: Case Studies 
 WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers.  Spotlight Cases  include interactive learning modules available for  CME/CPE . Commentaries are written by patient safety experts and published monthly. Have you encou… 
                                     
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction… 
                                     
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psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - Health Care Data Science for Quality Improvement and Patient Safety 
 Alvin Rajkomar, MD | October 1, 2016 
                       
 Also Read a Conversation  
 
 
 
 
 
 
 View more articles from the same authors. 
 
 
 
 
 
 
 Citation Text: 
 Rajkomar A. Health Care Data Science for Quality Improvement and Patient S… 
                                     
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psnet.ahrq.gov/web-mm/check-bags
January 03, 2017 - Check the Bags 
 
 
 
 
 Citation Text: 
 Caldwell M, Dracup KA. Check the Bags. 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 Endnote tagged PubMedId … 
                                     
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psnet.ahrq.gov/node/49860/psn-pdf
April 01, 2019 - Hip Fractures in Older Patients: the Case for Geriatrics
Comanagement
April 1, 2019
Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
The Case
An 82-year-old man … 
                                     
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psnet.ahrq.gov/web-mm/secured-not-always-safe
October 01, 2015 - Secured But Not Always Safe 
 
 
 
 
 Citation Text: 
 Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. 
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 Format: 
 
 
 
 Google Scholar BibTeX EndNote X3 XML EndNote 7 XML … 
                                     
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psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
March 04, 2020 - The Hidden Harms of Hand Sanitizer 
 
 
 
 
 Citation Text: 
 Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. 
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 Format: 
 
 
 
 Google Scholar BibTeX EndNote X3 XML EndNote 7 … 
                                     
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psnet.ahrq.gov/innovation/critical-radiology-alert-process
November 16, 2022 - Critical Radiology Alert Process  
 
 
 
 
 
 
 
 
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 Save to your library 
 
 
 
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 October 30, 2024 
 View more articles from the same authors. 
 
 
 
 Innovation 
 
 
 
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