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psnet.ahrq.gov/web-mm/thin-air
March 01, 2006 - SPOTLIGHT CASE
Thin Air
Citation Text:
Gaba DM. Thin Air. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL Dec Spotlight_Code Status vs Care Status.pptx
Spotlight
Code Status vs. Care Status
Source and Credits
• This presentation is based on the December 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Rebe…
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psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
October 04, 2023 - The Hidden Danger of Unseen Intravenous Catheters
Citation Text:
Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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digital.ahrq.gov/sites/default/files/docs/page/UHIN_BusinessCaseReport.pdf
November 01, 2005 - Establishing a Business Case for Health Information Exchange (HIE)
…
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effectivehealthcare.ahrq.gov/sites/default/files/hawley-presentation.pdf
May 29, 2025 - Hawley-notes-151016 copy - Teresa
This idea of focusing on patient-centered medical care has been one that’s come to
the forefront in the last decade and we’ve heard a lot about that.
1
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs018183-weiner-final-report-2013.pdf
January 01, 2013 - Medication Reconciliation Technology to Improve Quality of Transitional Care - Final Report
Grant Final Report
Grant ID: R18HS018183
Medication Reconciliation Technology to Improve
Quality of Transitional Care
Inclusive Project Dates: 09/30/09 – 07/31/13
Principal Investigator:
Michael Weiner
Team Member…
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - SPOTLIGHT CASE
The Wrong Shot: Error Disclosure
Citation Text:
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - The Consequences of Miscommunication Regarding a
Possible Artifact
June 30, 2021
Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
Disclosure of Relevant Financial Relationships…
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psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
January 29, 2020 - Delayed Recognition of a Positive Blood Culture
Citation Text:
Doernberg S. Delayed Recognition of a Positive Blood Culture. 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/inadequate-preanesthetic-evaluation-airway-trouble
November 01, 2023 - Inadequate Preanesthetic Evaluation, Airway Trouble
Citation Text:
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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meps.ahrq.gov/data_files/publications/st482/stat482.shtml
November 01, 2015 - STATISTICAL BRIEF #482:
Specialist Need and Access among Adults with Multiple Chronic Conditions, U.S. Civilian Noninstitutionalized Population, 2012
Skip to main content
An official website of the Department of He…
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psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line
Citation Text:
Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. 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/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
October 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue
Citation Text:
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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meps.ahrq.gov/data_files/publications/st409/stat409.shtml
June 01, 2013 - STATISTICAL BRIEF #409:
Heart Disease among Elderly Americans: Estimates for the U.S. Civilian Noninstitutionalized Population, 2010
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An official website of the Department of Health & Human Service…
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meps.ahrq.gov/data_files/publications/st440/stat440.shtml
June 01, 2014 - STATISTICAL BRIEF #440:
Expenditures for Treatment of Mental Health Disorders among Children, Ages 5-17, 2009-2011: Estimates for the U.S. Civilian Noninstitutionalized Population
Skip to main content
An official web…
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meps.ahrq.gov/data_files/publications/st393/stat393.shtml
November 01, 2012 - STATISTICAL BRIEF #393: Expenditures for Heart Disease among Adults Age 18 and Older: Estimates for the U.S. Civilian Noninstitutionalized Population, 2009
Skip to main content
An official website of the Department of He…
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meps.ahrq.gov/data_files/publications/st370/stat370.shtml
May 01, 2012 - STATISTICAL BRIEF #370:
Health and Insurance Status, Health Care Use, and Expenditures for Male Veterans, 2008: Estimates for the U.S. Civilian Noninstitutionalized Population
Skip to main content
An official website …
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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…
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psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - Root Cause Analysis Gone Wrong
May 1, 2018
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
The Case
A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney
transplant. A suitabl…
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psnet.ahrq.gov/node/865778/psn-pdf
May 29, 2024 - Navigating Complications: The Unintended Journey of a
Guidewire During Dialysis Catheter Placement
May 29, 2024
Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis
Catheter Placement. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-complications-unint…