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psnet.ahrq.gov/web-mm/dropped-no
October 30, 2019 - The Dropped "No"
Citation Text:
Johnson AJ. The Dropped "No". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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…
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psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization
Citation Text:
Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/pathologic-mistake
February 15, 2010 - Pathologic Mistake
Citation Text:
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/node/49612/psn-pdf
November 01, 2010 - Treatment Challenges After Discharge
November 1, 2010
Coffey C. Treatment Challenges After Discharge. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
Case Objectives
Understand types and frequencies of adverse events occurring between patient discharge from the
hospital …
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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - Diagnostic Overshadowing Dangers
Citation Text:
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/departure-central-line-ritual
October 13, 2018 - Departure From Central Line Ritual
Citation Text:
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
October 01, 2018 - CVC Removal: A Procedure Like Any Other
Citation Text:
Feil M. CVC Removal: A Procedure Like Any Other. 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/49411/psn-pdf
July 01, 2003 - Code Status Confusion
July 1, 2003
Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/code-status-confusion
Case Objectives
Appreciate challenges of determining goals of care in hospitalized patients
Understand patients’ common misconceptions about CPR
List typical mist…
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psnet.ahrq.gov/node/49627/psn-pdf
June 01, 2011 - The ECG Is Not Normal
June 1, 2011
Zuger A. The ECG Is Not Normal. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/ecg-not-normal
Case Objectives
State how frequently physicians care for family or relatives.
Describe the risks associated with caring for family members or relatives.
Appreciate some of the s…
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psnet.ahrq.gov/web-mm/urinary-retention-dilemma
March 01, 2013 - Urinary Retention Dilemma
Citation Text:
Joseph AC. Urinary Retention Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/49664/psn-pdf
January 01, 2013 - Empty Handoff
September 1, 2012
Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/empty-handoff
The Case
A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a
leg wound. The patient's medical history included chronic…
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psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure
July 01, 2017 - Shortcuts to Acetaminophen-induced Liver Failure
Citation Text:
Bacak S, Thornburg L. Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/49787/psn-pdf
March 01, 2017 - Diagnosing a Missed Diagnosis
March 1, 2017
Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
The Case
A 57-year old woman was admitted to the hospital with cough, slurred speech, confusion, and
disorientation. She was taking mod…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
May 01, 2017 - PowerPoint Presentation
Spotlight
Diagnostic Delay in the Emergency Department
1
Source and Credits
This presentation is based on the May 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Kyle Marshall, MD, Geisinger Medical Center, Danv…
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psnet.ahrq.gov/web-mm/ectopic-or-not
March 27, 2024 - Ectopic or Not?
Citation Text:
Givens VM, Lipscomb GH. Ectopic or Not?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/49461/psn-pdf
September 01, 2004 - Reaction to Dye
September 1, 2004
Cohan R. Reaction to Dye. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/reaction-dye
The Case
A patient was referred to urology after having several episodes of gross hematuria. The urologist thought
that the patient might have a renal mass and sent him to radiology for a…
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psnet.ahrq.gov/node/33596/psn-pdf
June 01, 2025 - Failure to Rescue
January 29, 2025
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/failure-rescue
Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet
primers are regularly reviewed and updated to ensure that they reflect cur…
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psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
September 01, 2012 - Add-on Case and the Missing Checklist
Citation Text:
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/other-hand
December 12, 2012 - On the Other Hand
Citation Text:
Henneman EA. On the Other Hand. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/49783/psn-pdf
February 01, 2017 - The Hazards of Distraction: Ticking All the EHR Boxes
February 1, 2017
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
Case Objectives
List the goals of having order sets in the electronic health record…