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psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
November 01, 2008 - In Conversation with…Sanjay Saint, MD, MPH
November 1, 2008
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Citation Text:
In Conversation with…Sanjay Saint, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 200…
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psnet.ahrq.gov/node/73202/psn-pdf
April 28, 2021 - A Postpartum Woman with an Erroneous SARS-CoV-2
Test
April 28, 2021
Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
The Case
A full-term pregnant patient was admitted in March 2…
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psnet.ahrq.gov/node/851971/psn-pdf
July 31, 2023 - Failure to Adhere to Dietary Restrictions Leading to
Complications and Poor Follow-up
July 31, 2023
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications
and poor follow-up. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/failure-adhere-dietary-restricti…
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psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The Problem and Solutions
Lindsay E. Nicolle, MD | November 1, 2008
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Citation Text:
Nicolle LE. Health Care–Acquired Urinary Tract Infection: The Pr…
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psnet.ahrq.gov/node/84413/psn-pdf
February 23, 2022 - A Loss of Trust and a Missed Diagnosis
February 23, 2022
Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counci…
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psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
September 01, 2005 - In Conversation with…Carolyn Clancy, MD
September 1, 2005
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Citation Text:
In Conversation with…Carolyn Clancy, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
…
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psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety
April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety
Brian K. Alldredge, PharmD; Mary Anne Koda-Kimble, PharmD | April 1, 2006
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Alldredge BK, Koda-Kimb…
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psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
February 26, 2025 - In Conversation With… Sigall K. Bell, MD
September 1, 2018
Citation Text:
In Conversation With… Sigall K. Bell, MD. 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/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
January 01, 2024 - Spotlight
Hindsight is 20/20: Thrombolytics for Alcohol
Intoxication
Source and Credits
• This presentation is based on the April 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Eric Signoff, MD, Noelle Boctor, MD, and David K.
B…
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psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - Failure to Ensure Patient Safety Leads to Patient Falls in
Nursing Homes.
April 26, 2023
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
Disclosure of Relevant Financial R…
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - WebM&M: Case Studies
WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME/CPE . Commentaries are written by patient safety experts and published monthly. Have you encou…
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psnet.ahrq.gov/node/846171/psn-pdf
July 26, 2022 - Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
March 15, 2023
Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of
Gastric Perforation. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/agitated-delirium-contributes…
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
April 01, 2006 - In Conversation with… Michael Cohen, RPh, MS, ScD (hon)
April 1, 2006
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Citation Text:
In Conversation with… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …
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psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
September 27, 2023 - SPOTLIGHT CASE
Missed Opportunities for Suicide Risk Assessment
Citation Text:
Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. 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/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis
May 26, 2021 - Endometriosis: A Common and Commonly Missed and Delayed Diagnosis
Citation Text:
Mackenzie M, Royce C. Endometriosis: A Common and Commonly Missed and Delayed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - Patient Safety in Frail Older Patients
November 26, 2019
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View more articles from the same authors.
Citation Text:
Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. Rockville (MD): Agency for Healthc…
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psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
March 27, 2024 - SPOTLIGHT CASE
Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head
Citation Text:
Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
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psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
October 02, 2024 - Safety I, Safety II, and the New Views of Safety
Citation Text:
Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - In Conversation With... David Gruen, MD
January 31, 2020
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Citation Text:
In Conversation With.. David Gruen, MD. PSNet [internet]. 2020.In Conversation With... David Gruen, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research an…