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psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
November 03, 2015 - February 16, 2022
Planning for a pandemic: mitigating risk to radiation therapy service
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psnet.ahrq.gov/node/49434/psn-pdf
February 01, 2004 - After undergoing radiation therapy and chemotherapy, she still has persistent disease.
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psnet.ahrq.gov/web-mm/more-treatment-better-care
August 11, 2021 - More Treatment—Better Care?
Citation Text:
Redberg R. More Treatment—Better Care?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/49673/psn-pdf
December 01, 2012 - A Real Heartache
December 1, 2012
Polevoi SK. A Real Heartache. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/real-heartache
The Case
A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The
pain began at rest, and it radiated to his back and left axilla. He had…
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psnet.ahrq.gov/node/49682/psn-pdf
April 01, 2013 - From Possible to Probable to Sure to Wrong—Premature
Closure and Anchoring in a Complicated Case
April 1, 2013
Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a
Complicated Case. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premat…
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psnet.ahrq.gov/issue/free-lessons-aviation-safety
October 19, 2022 - June 28, 2023
Quality and Safety Considerations in Intensity Modulated Radiation Therapy
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psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
July 06, 2022 - After undergoing radiation therapy and chemotherapy, she still has persistent disease.
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psnet.ahrq.gov/issue/team-resource-management-and-patient-safety-team-focused-approach-clinical-governance
August 26, 2015 - Study
Team resource management and patient safety: a team focused approach to clinical governance.
Citation Text:
Boddington R, Arthur H, Cummings D, et al. Team Resource Management and patient safety. Clinical Governance: An International Journal. 2006;11(1). doi:10.1108/1477727061064…
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psnet.ahrq.gov/issue/hospitals-tackle-high-risk-drugs-reduce-errors
October 07, 2015 - Newspaper/Magazine Article
Hospitals tackle high-risk drugs to reduce errors.
Citation Text:
Landro L.
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March 19, 2008
Landr…
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psnet.ahrq.gov/issue/surgical-mistakes-persist-bay-state-still-tiny-fraction-total-procedures
September 10, 2014 - Newspaper/Magazine Article
Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.
Citation Text:
Kowalczyk L.
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…
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case
Citation Text:
Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US …
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psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - Spinal Epidural Abscess
Citation Text:
Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/periodic-issue/periodic-issue-283
March 15, 2021 - March 17, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/issue/use-cellular-telephones-hospital-environment
November 26, 2014 - June 21, 2023
Quality and Safety Considerations in Intensity Modulated Radiation Therapy
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only
Spotlight
Delay in Appropriate Diagnosis and
Treatment Leading to Death from
Pulmonary Embolism
Source and Credits
• This presentation is based on the February 2021 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
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psnet.ahrq.gov/issue/distractors-obstetric-ultrasound-do-sonographers-have-safety-concerns
March 08, 2023 - April 6, 2016
Planning for a pandemic: mitigating risk to radiation therapy service delivery
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psnet.ahrq.gov/node/866618/psn-pdf
December 31, 2024 - A Fatal Twist in Pseudohyperkalemia
December 31, 2024
Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council
for C…
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psnet.ahrq.gov/node/73902/psn-pdf
September 29, 2021 - Dangers of Missing an Epidural Abscess: Multiple Visits
and Delayed Diagnosis with a Severely Negative Outcome
September 29, 2021
Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed
Diagnosis with a Severely Negative Outcome. PSNet [internet]. 2021.
https://psnet.ahrq.go…
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - Spotlight
Spotlight
Dangers of Missing an Epidural Abscess:
Multiple Visits and Delayed Diagnosis with
a Severely Negative Outcome
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Comm…
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psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
December 31, 2024 - SPOTLIGHT CASE
Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism
Citation Text:
McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…