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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49770/psn-pdf
    September 01, 2016 - Wrong-Time Error With High-Alert Medication September 1, 2016 Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication The Case A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…
  2. psnet.ahrq.gov/web-mm/autopsy-revelation
    December 01, 2007 - Autopsy Revelation Citation Text: Shojania KG. Autopsy Revelation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73455/psn-pdf
    June 30, 2021 - Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks June 30, 2021 Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks The Case At the…
  4. psnet.ahrq.gov/web-mm/picking-cause-stroke
    August 07, 2024 - Picking Up the Cause of the Stroke Citation Text: Chopra V. Picking Up the Cause of the Stroke. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
  5. psnet.ahrq.gov/web-mm/too-tight-control
    March 20, 2013 - SPOTLIGHT CASE Too Tight Control Citation Text: Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49540/psn-pdf
    August 21, 2007 - Resuscitation Errors: A Shocking Problem August 21, 2007 Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem Case Objectives Appreciate that delays in defibrillation can have significant negative effects on sur…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33729/psn-pdf
    May 01, 2012 - The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety May 1, 2012 Sharek PJ. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-pa…
  8. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.101_slideshow.ppt
    July 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case July 2005 Impatient Inpatient Dosing Source and Credits This presentation is based on the July 2005 AHRQ WebM&M Spotlight Case in Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Richard H. White…
  9. psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx Spotlight Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the ful…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49798/psn-pdf
    July 01, 2017 - Pseudo-obstruction But a Real Perforation July 1, 2017 Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation Case Objectives Recognize acute colonic pseudo-obstruction and implement a medical management plan. Ide…
  11. Spotlight (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
    January 01, 2019 - Spotlight Spotlight Mistaken Attribution, Diagnostic Misstep * Source and Credits This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49485/psn-pdf
    August 29, 2024 - Blind Spot June 1, 2005 Lee LA. Blind Spot. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/blind-spot The Case A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49584/psn-pdf
    April 01, 2009 - EMR Entry Error: Not So Benign April 1, 2009 Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign The Case A 47-year-old man with advanced AIDS was admitted to an academic medical center with a chief complaint of shortness of breath. He was …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50392/psn-pdf
    September 01, 2019 - In Conversation With… Shantanu Agrawal, MD, MPhil September 1, 2019 In Conversation With… Shantanu Agrawal, MD, MPhil. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil Editor's note: Dr. Agrawal is president and CEO of the National Quality Forum (NQF). He is the form…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49437/psn-pdf
    March 01, 2004 - Crossing the Line March 1, 2004 Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/crossing-line Case Objectives Review complications of central venous catheterization Discuss patient and operator factors that affect complication rates Describe methods for preventing c…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49501/psn-pdf
    February 03, 2006 - Lost in Transition February 1, 2006 Beach C. Lost in Transition. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/lost-transition Case Objectives Provide an overview of transitions in continuously operating industries Review cognitive error Describe the complex dynamics of transitions in emergency care Pro…
  17. psnet.ahrq.gov/continuing-education
    February 26, 2025 - Continuing Education What is PSNet Continuing Education? PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of Calif…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49531/psn-pdf
    March 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses…
  19. psnet.ahrq.gov/web-mm/undetected-foreign-object
    April 24, 2018 - Undetected Foreign Object Citation Text: Cima RR. Undetected Foreign Object. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
  20. psnet.ahrq.gov/curated-library/diagnostic-error
    September 14, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Diagnostic Error  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Karen Cosby, AHRQ Date Created: May 8, …

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