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  1. Right Regimen, Wrong Cancer: Patient Catches Medical Error | PSNet

    psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
    August 01, 2006 - SPOTLIGHT CASE Right Regimen, Wrong Cancer: Patient Catches Medical Error Citation Text: Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60610/psn-pdf
    June 24, 2020 - Endometriosis: A Common and Commonly Missed and Delayed Diagnosis June 24, 2020 Mackenzie M, Royce C. Endometriosis: A Common and Commonly Missed and Delayed Diagnosis. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis   The Case A 15-year-old g…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74121/psn-pdf
    November 30, 2021 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. November 30, 2021 Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emerg…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49611/psn-pdf
    October 01, 2010 - The Deadly Duo October 1, 2010 Maldonado JR. The Deadly Duo. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/deadly-duo The Case A 29-year-old man with a history of depression and possible psychosis was found unconscious and unresponsive at home and was brought to the emergency department. He was tachycardi…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33787/psn-pdf
    January 01, 2018 - In Conversation With… Maureen Bisognano June 1, 2015 In Conversation With… Maureen Bisognano. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-maureen-bisognano Editor's note: Maureen Bisognano is President and CEO of the Institute for Healthcare Improvement (IHI). We spoke with her about I…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49723/psn-pdf
    January 01, 2015 - Monitoring Fetal Health January 1, 2015 Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/monitoring-fetal-health Case Objectives Define fetal heart rate monitoring. Describe the current state of evidence regarding fetal heart rate monitoring. List the known …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33831/psn-pdf
    April 01, 2017 - In Conversation With… Mark Chassin, MD, MPP, MPH April 1, 2017 In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph Editor's note: Dr. Chassin is president and chief executive officer of The Joint Commission. He is also p…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33783/psn-pdf
    April 01, 2015 - In Conversation With… Lucian Leape, MD April 1, 2015 In Conversation With… Lucian Leape, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-lucian-leape-md Editor's note: Dr. Lucian Leape is Adjunct Professor of Health Policy at the Harvard School of Public Health, Chairman of the Lucian …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33760/psn-pdf
    February 01, 2014 - In Conversation With… Enrico Coiera, MB, BS, PhD February 1, 2014 In Conversation With… Enrico Coiera, MB, BS, PhD. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd Editor's note: Enrico Coiera, MB, BS, PhD, is a professor and director of the Centre for Health Informa…

  10. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency | PSNet

    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…

  11. Suicide Prevention in an Emergency Department Population: ED-SAFE | PSNet

    psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
    July 23, 2024 - Suicide Prevention in an Emergency Department Population: ED-SAFE Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL April 24, 2024 View more articles from the same authors. Innovation …

  12. The Forgotten Turn | PSNet

    psnet.ahrq.gov/web-mm/forgotten-turn
    August 01, 2018 - SPOTLIGHT CASE The Forgotten Turn Citation Text: Barbour S. The Forgotten Turn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…

  13. Psn-Pdf (pdf file)

    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…

  14. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination | PSNet

    psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-physical-examination
    April 29, 2020 - Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination Citation Text: Valdes W, Utter GH. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Hea…

  15. Dissecting the Presentation | PSNet

    psnet.ahrq.gov/web-mm/dissecting-presentation
    May 05, 2021 - SPOTLIGHT CASE Dissecting the Presentation Citation Text: Suat-Ooi SB. Dissecting the Presentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 …

  16. Psn-Pdf (pdf file)

    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-…

  17. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
    January 01, 2022 - Spotlight Spotlight Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong Source and Credits • This presentation is based on the October 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary…

  18. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | PSNet

    psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
    October 01, 2004 - SPOTLIGHT CASE Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Citation Text: Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. Rockville (MD): Agency for Healthcare Res…

  19. The Pains of Chronic Opioid Usage | PSNet

    psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
    April 04, 2018 - SPOTLIGHT CASE The Pains of Chronic Opioid Usage Citation Text: Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google S…

  20. New Insights on Safety and Health IT | PSNet

    psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
    August 01, 2015 - Some offer best practice recommendations, drawn from the literature or prior implementations.
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