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psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
October 27, 2021 - November 29, 2023
The Pursuing Excellence Collaborative: engaging first-year residents
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.350_slideshow.ppt
June 01, 2015 - another doctor thought that the patient might have coronary heart disease
In a different study, medical residents
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psnet.ahrq.gov/web-mm/refused-medication-error
November 01, 2005 - June 3, 2010
Readiness of US general surgery residents for independent practice.
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - mistaken-dose-naloxone
The Commentary
By Erika Cutler, PharmD, and Delani Gunawardena, MD
More than 700,000 US residents
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psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-improves-maternal-and
September 23, 2024 - Innovations
Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents
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psnet.ahrq.gov/node/33596/psn-pdf
January 29, 2025 - low rates of FTR also reported
more inpatient support, higher rates of employing hospitalists and residents
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psnet.ahrq.gov/web-mm/paradoxical-pulse
May 01, 2013 - Despite the countless hours spent by students, residents, and faculty gazing at neck veins, the overall
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psnet.ahrq.gov/web-mm/air-side-caution
April 21, 2015 - Effects of fatigue on residents' performance in laparoscopy. J Am Coll Surg. 2015;221:564-570.e3.
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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - Interprofessional conflict and medical errors: results of a national multi-
specialty survey of hospital residents
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psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
January 29, 2020 - Potentially avoidable hospitalizations among historically marginalized nursing home residents
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - SPOTLIGHT CASE
Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome
Citation Text:
Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet…
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psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things Changed?
Helen Haskell, MA | June 1, 2014
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Haskell H. Patient Advocacy in Patient Safety: Have Things Changed?. PSNet [internet]. Ro…
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psnet.ahrq.gov/primer/health-literacy
September 07, 2019 - Health Literacy
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September 7, 2019
Background
Health literacy is defined as an individual's ability to find, process, and comprehend the basic health information necessary…
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psnet.ahrq.gov/issue/teamstepps-health-care-risk-managers-improving-teamwork-and-communication
March 27, 2019 - Commentary
TeamSTEPPS for health care risk managers: improving teamwork and communication.
Citation Text:
Cooke M. TeamSTEPPS for health care risk managers: Improving teamwork and communication. J Healthc Risk Manag. 2016;36(1):35-45. doi:10.1002/jhrm.21233.
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Format:
…
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psnet.ahrq.gov/node/49766/psn-pdf
August 21, 2016 - Getting the (Right) Doctor, Right Away
August 21, 2016
Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
The Case
A 57-year-old woman with a history of chronic obstructive pulmonary disease underwent hip surgery.
Postop…
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psnet.ahrq.gov/node/50615/psn-pdf
October 30, 2019 - Misidentifying the Unidentified – John Doe and the EHR
October 30, 2019
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
The Case
Two male patients of similar age arrived at the same …
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psnet.ahrq.gov/node/867004/psn-pdf
October 30, 2024 - Critical Radiology Alert Process
October 30, 2024
https://psnet.ahrq.gov/innovation/critical-radiology-alert-process
Summary
Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of
unrelated abnormal findings and provides a companion follow-up process, with the goal o…
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psnet.ahrq.gov/node/49658/psn-pdf
July 01, 2012 - Misleading Complaint
July 1, 2012
Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/misleading-complaint
The Case
A 54-year-old homeless man with a history of alcoholism presented to the emergency department (ED) with
complaints of knee problems. The triage nurse docu…
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psnet.ahrq.gov/node/49565/psn-pdf
July 01, 2008 - Wrong Route for Nutrients
July 1, 2008
Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wrong-route-nutrients
The Case
An 82-year-old man living in a skilled nursing facility (SNF) had not been eating or drinking well for about 6
months. He had lost weight and d…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
May 01, 2013 - Spotlight Case July 2008
Spotlight Case
Right Regimen, Wrong Cancer: Patient Catches Medical Error
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Source and Credits
This presentation is based on the May 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Joseph O. Jacobson, MD, MSc…