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  1. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - Spotlight Spotlight Fatal PCA Opioid-Induced Respiratory Depression Source and Credits • This presentation is based on the May 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP o Editors in Chie…
  2. psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
    February 26, 2025 - In Conversation With… Kaveh Shojania, MD November 1, 2015  Citation Text: In Conversation With… Kaveh Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…
  3. psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
    February 01, 2011 - The University of Texas System Clinical Safety and Effectiveness Course Eric J. Thomas, MD, MPH; Jan Patterson, MD, MS; Sherry Martin, MEd; Doris Quinn, PhD; Gary Reed, MD; Ken Shine, MD | February 1, 2011  View more articles from the same authors. Citation Text: T…
  4. psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
    September 27, 2023 - SPOTLIGHT CASE Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation Citation Text: Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation. PSNet [internet]. Rockville (MD): Agency for Health…
  5. psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
    January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx Spotlight A Loss of Trust and a Missed Diagnosis Source and Credits • This presentation is based on the February 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.…
  6. psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
    March 31, 2021 - SPOTLIGHT CASE Delayed Diagnosis of Mesenteric Ischemia Citation Text: Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861738/psn-pdf
    January 31, 2024 - A Laceration that Needed a Proper Exam, Not an X-Ray January 31, 2024 Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray Disclosure of Relevant Financial Relationships: As a provider accredited by t…
  8. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
    January 01, 2024 - Spotlight Spotlight Laceration that Needed a Proper Exam, Not an X-Ray Source and Credits • This presentation is based on the January 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Jazmin A. Wander, MD and David K. Barnes, MD, F…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837963/psn-pdf
    August 31, 2022 - Delayed Diagnosis of Mesenteric Ischemia August 31, 2022 Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861760/psn-pdf
    January 31, 2024 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery January 31, 2024 Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837748/psn-pdf
    August 05, 2022 - Challenges of Diabetes Management and Medication Reconciliation August 5, 2022 Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation The Cases Case #1: A 53-year-old man …
  12. psnet.ahrq.gov/classics
    August 01, 2023 - Classics and Emerging Classics To help our readers navigate the tremendous breadth of the PSNet Collection, AHRQ PSNet editors and advisors have given the designation of “Classic” to review articles, empirical studies, government and stakeholder reports, commentaries, and books of lasting importance to the patient sa…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33759/psn-pdf
    October 01, 2012 - Promising Areas for Patient Safety Research December 1, 2003 Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. PSNet [internet]. 2003. https://psnet.ahrq.gov/perspective/promising-areas-patient-safety-research Perspective Setting a Course for Patient Safety Research Although patient safety…
  14. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
    December 01, 2004 - test results, discharge medication list, or sufficient details about admission diagnosis or follow-up plans … Follow up plans Discharge clinic Follow-up phone calls Appointments/access to primary providers
  15. psnet.ahrq.gov/issue/effect-quality-improvement-intervention-daily-round-checklists-goal-setting-and-clinician
    June 25, 2014 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans
  16. psnet.ahrq.gov/issue/protocol-based-computer-reminders-quality-care-and-non-perfectability-man
    April 24, 2018 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans
  17. psnet.ahrq.gov/issue/validity-selected-ahrq-patient-safety-indicators-based-va-national-surgical-quality
    July 14, 2009 - June 9, 2021 Rates of serious surgical errors in California and plans to prevent recurrence
  18. psnet.ahrq.gov/issue/estimating-deaths-due-medical-error-ongoing-controversy-and-why-it-matters
    December 30, 2014 - January 23, 2019 Risk controls identified in action plans following serious incident
  19. psnet.ahrq.gov/issue/strategies-safe-interhospital-transfer-intubated-patient-or-where-readiness-intubation-needed
    July 31, 2013 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans
  20. psnet.ahrq.gov/issue/how-not-waste-crisis-qualitative-study-problem-definition-and-its-consequences-three
    April 21, 2015 - August 21, 2013 Risk controls identified in action plans following serious incident investigations

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