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  1. psnet.ahrq.gov/primer/individual-clinician-performance-issues
    March 15, 2025 - Individual Clinician Performance Issues Citation Text: Individual Clinician Performance Issues. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849598/psn-pdf
    May 31, 2023 - Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis May 31, 2023 https://psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve- management-sepsis Summary Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidiscip…
  3. psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
    December 14, 2022 - In Conversation with... Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS December 14, 2022  Also Read the Essay Citation Text: In Conversation with.. Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS. PSNet [internet]. 2022.In Conversation with... Ellen Deutsch, MD, MS, …
  4. 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. …
  5. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-11/spotlight_integration_and_coordination_of_disesase_treatment_and_palliative_care_final.pdf
    January 01, 2021 - Spotlight Spotlight Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care Source and Credits • This presentation is based on the November 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Han…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845472/psn-pdf
    March 15, 2023 - In Conversation with... Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring March 15, 2023 In Conversation with.. Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-…
  7. psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
    December 14, 2022 - Resilient Healthcare and the Safety-I and Safety-II Frameworks December 14, 2022  Also Read the Conversation View more articles from the same authors. Citation Text: Deutsch ES, Van CM, Mossburg SE. Resilient Healthcare and the Safety-I and Safety-II Frameworks.…
  8. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-12/spotlight_case_strongyloides_final_11.21.22.pdf
    January 01, 2022 - Spotlight Spotlight Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis Source and Credits • This presentation is based on the November 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Narath Carlile MD MPH,…
  9. 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…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49769/psn-pdf
    September 01, 2016 - Complaints as Safety Surveillance September 1, 2016 Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance The Case A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain came on sudden…
  11. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
    July 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case July 2007 Resuscitation Errors: A Shocking Problem Source and Credits This presentation is based on the July 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available online Commentary by: Benjamin Abella, MD, MPhil, …
  12. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.368_slideshow.ppt
    February 01, 2016 - PowerPoint Presentation Spotlight Robotic Surgery: Risks vs. Rewards 1 Source and Credits This presentation is based on the February 2016 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Tara Kirkpatrick, MD, and Chad LaGrange, MD, Univer…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33751/psn-pdf
    January 01, 2014 - Strengthening the Business Case for Patient Safety May 1, 2013 Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety Perspective After more than a decade in the national spotlight, the problem of pati…
  14. 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…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49731/psn-pdf
    April 01, 2015 - Fire in the Hole!—An OR Fire April 1, 2015 Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fire-hole-or-fire The Case A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection for a biopsy-proven adenocarcinom…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49694/psn-pdf
    October 01, 2013 - Are You Mrs. A? An Issue of Identification Over Telephone October 1, 2013 Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone The Case Mr. A was a 78-year-old man admitted with non-ST elevation…
  17. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
    May 01, 2015 - PowerPoint Presentation Spotlight Errors in Sepsis Management This presentation is based on the May 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: David Shimabukuro, MD, University of California, San Francisco (UCSF) Editor, AHRQ WebM&M: Rober…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49526/psn-pdf
    December 01, 2006 - Crossing the Borderline December 1, 2006 Oldham JM. Crossing the Borderline. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/crossing-borderline The Case A 24-year-old woman with borderline personality disorder was admitted to an inpatient psychiatry unit following a failed suicide attempt with excess doses…
  19. 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…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73335/psn-pdf
    May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition Error May 26, 2021 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error The Case A 4-year-old (former 33-week premature) boy with a …

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