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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - SPOTLIGHT CASE
A Lot of Pain (Medications)
Citation Text:
Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/49537/psn-pdf
June 01, 2007 - Beeline to Spine
June 1, 2007
Smetana GW. Beeline to Spine. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/beeline-spine
Case Objectives
Understand the elements of preoperative medical evaluation.
Appreciate the limited role for preoperative laboratory testing.
Appreciate the importance of communication a…
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psnet.ahrq.gov/node/865429/psn-pdf
April 24, 2024 - For this reason, the clinicians in this case were trying to rapidly cardiovert the patient back to
sinus
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psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
January 01, 2024 - • For this reason, the clinicians in this case were trying to rapidly cardiovert the
patient back
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…
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psnet.ahrq.gov/issue/diagnostic-quality-improvement-repository
November 08, 2017 - Database/Directory
Diagnostic Quality Improvement Repository.
Citation Text:
Diagnostic Quality Improvement Repository. Society to Improve Diagnosis in Medicine.
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psnet.ahrq.gov/node/46676/psn-pdf
December 13, 2017 - Diagnostic errors by medical students: results of a
prospective qualitative study.
December 13, 2017
Braun LT, Zwaan L, Kiesewetter J, et al. Diagnostic errors by medical students: results of a prospective
qualitative study. BMC Med Educ. 2017;17(1):191. doi:10.1186/s12909-017-1044-7.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/issue/monitoring-diagnostic-process-inpatient-neurology-service
November 03, 2015 - Study
Monitoring the diagnostic process on an inpatient neurology service.
Citation Text:
Dhand A, Bucelli R, Varadhachary A, et al. Monitoring the Diagnostic Process on an Inpatient Neurology Service. Neurohospitalist. 2017;7(3):132-136. doi:10.1177/1941874416677681.
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psnet.ahrq.gov/issue/screen-savers-adjunct-medical-education-patient-safety
March 03, 2010 - Study
Screen savers as an adjunct to medical education on patient safety.
Citation Text:
Screen savers as an adjunct to medical education on patient safety. Coil CJ; Kaji AH; Crevensten H; Aaron KE; Lewis RJ; Coates WC.
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psnet.ahrq.gov/node/45670/psn-pdf
November 16, 2016 - Not thinking clearly? Play a game, seriously!
November 16, 2016
Mohan D, Schell J, Angus DC. Not Thinking Clearly? Play a Game, Seriously!. JAMA. 2016;316(18):1867-
1868. doi:10.1001/jama.2016.14174.
https://psnet.ahrq.gov/issue/not-thinking-clearly-play-game-seriously
Heuristics enable experts to build off their …
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psnet.ahrq.gov/node/46172/psn-pdf
June 21, 2017 - Flying lessons for clinicians: developing system 2
practice.
June 21, 2017
Gregoire JN, Alfes CM, Reimer AP, et al. Flying Lessons for Clinicians: Developing System 2 Practice. Air
Med J. 2017;36(3):135-137. doi:10.1016/j.amj.2017.02.003.
https://psnet.ahrq.gov/issue/flying-lessons-clinicians-developing-system-2-p…
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psnet.ahrq.gov/node/49701/psn-pdf
February 01, 2014 - An Easily Forgotten Tube
February 1, 2014
Ousey K. An Easily Forgotten Tube. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/easily-forgotten-tube
The Case
A 45-year-old man was admitted to the intensive care unit (ICU) for acute liver failure secondary to alcohol
abuse. His illness was complicated by acute…
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psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
January 01, 2014 - Annual Perspective
Computerized Provider Order Entry and Patient Safety
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015
View more articles from the same authors.
Citation Text:
Sarkar U, Shojania KG. Computerized Provider Order Entry and Patien…
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psnet.ahrq.gov/perspective/patient-engagement-safety
January 01, 2018 - Annual Perspective
Patient Engagement in Safety
Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2017
View more articles from the same authors.
Citation Text:
Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. Rockville (MD): Agency…
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psnet.ahrq.gov/node/49867/psn-pdf
July 02, 2019 - Diuretics and Electrolyte Abnormalities
July 2, 2019
Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
Case Objectives
Recognize that thiazide diuretics can lead to serious adverse events.
State how commonly used t…
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psnet.ahrq.gov/node/60548/psn-pdf
May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD
May 28, 2020
In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at
the Food…
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psnet.ahrq.gov/node/867980/psn-pdf
March 25, 2025 - Not All Headaches are Due to Migraine: Red Flags, Don’t
Miss Diagnoses, and Diagnostic Pitfalls
March 25, 2025
Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic
Pitfalls. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-fla…
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psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety
September 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety
Citation Text:
Fatigue, Sleep Deprivation, and Patient Safety. 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/perspective/accountability-patient-safety
January 01, 2018 - Annual Perspective
Accountability in Patient Safety
Christopher Moriates, MD, and Robert M. Wachter, MD | January 1, 2015
View more articles from the same authors.
Citation Text:
Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. Rock…
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psnet.ahrq.gov/node/45617/psn-pdf
November 30, 2016 - Walking a tightrope: balancing the risk of diagnostic error
in inpatient pediatrics.
November 30, 2016
Berkwitt A, Osborn R, Grossman M. Walking a Tightrope: Balancing the Risk of Diagnostic Error in
Inpatient Pediatrics. Hosp Pediatr. 2016;6(9):566-8. doi:10.1542/hpeds.2016-0043.
https://psnet.ahrq.gov/issue/walk…