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psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
May 01, 2018 - SPOTLIGHT CASE
Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency
Citation Text:
Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
January 13, 2010 - SPOTLIGHT CASE
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
Citation Text:
Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - Delayed Breast Cancer Diagnosis: A False Sense of Security.
Citation Text:
Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
September 25, 2019 - SPOTLIGHT CASE
Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery.
Citation Text:
Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research …
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psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near-
Miss Wrong Transfusion Event
January 29, 2020
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
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psnet.ahrq.gov/node/851099/psn-pdf
June 28, 2023 - Misconnection Leading to Arterial Thrombosis
June 28, 2023
Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
The Case
A 55-year-old man with chronic obstructive pulmonary disease (COPD) was brought by am…
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psnet.ahrq.gov/node/838900/psn-pdf
October 27, 2022 - Fecal Contamination of the Peritoneum from
Laparoscopic Trocar Injury: A Routine Operation Goes
Wrong.
October 27, 2022
Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine
Operation Goes Wrong. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/fecal-contamination-…
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psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - Patient and Family Roles in Safety
Beverley H. Johnson, FAAN, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD
| June 14, 2023
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Johnson B, Lee M, Mossburg S. Patient and Fam…
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
June 14, 2023 - In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm
Beverley H. Johnson, FAAN
| June 14, 2023
Also Read the Essay
View more articles from the same authors.
Citation Text:
Johnson B. In Conversation with.. Beverley H…
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - SPOTLIGHT CASE
A Laceration that Needed a Proper Exam, Not an X-Ray
Citation Text:
Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - SPOTLIGHT CASE
Total Parenteral Nutrition, Multifarious Errors
Citation Text:
Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
…
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - Lack of Sepsis Recognition Leads to Delay in Care
Following Cesarean Delivery.
November 25, 2020
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean
Delivery. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesare…
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psnet.ahrq.gov/web-mm/deadly-duo
April 28, 2021 - The Deadly Duo
Citation Text:
Maldonado JR. The Deadly Duo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Intraoperative Awareness during Rhinoplasty
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Christian Bohringer MBBS and Jaijeet Toor MD
AHRQ WebM&M Edit…
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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - SPOTLIGHT CASE
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.
Citation Text:
Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.. PSNet [internet]. Rockville (MD): Agency fo…
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psnet.ahrq.gov/node/867022/psn-pdf
October 30, 2024 - Delayed Symptomatic Subdural Hematoma Following an
Initially Normal CT Head
October 30, 2024
Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-h…
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psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
August 14, 2024 - SPOTLIGHT CASE
Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.
Citation Text:
Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…
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psnet.ahrq.gov/web-mm/what-was-those-platelets
August 28, 2024 - What Was in Those Platelets?
Citation Text:
Yomtovian R. What Was in Those Platelets? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - SPOTLIGHT CASE
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.
Citation Text:
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
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psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
February 01, 2006 - Removing Insult from Injury—Disclosing Adverse Events
Albert W. Wu, MD, MPH | February 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wu AW. Removing Insult from Injury—Disclosing Adverse Events. PSNet [internet]. Rock…