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psnet.ahrq.gov/node/838855/psn-pdf
October 27, 2022 - False Assumptions Result in a Missed Pneumothorax
after Bronchoscopy with Transbronchial Biopsy.
October 27, 2022
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy
with Transbronchial Biopsy. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/false-assumptions-resul…
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psnet.ahrq.gov/node/49482/psn-pdf
May 01, 2005 - Pregnant With Danger
May 1, 2005
Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pregnant-danger
The Case
A 35-year-old woman, 38 weeks pregnant, presented to the emergency department (ED) in the middle of
the night complaining of left leg pain. She also had so…
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psnet.ahrq.gov/node/49480/psn-pdf
May 01, 2005 - Diagnosing Diagnostic Mistakes
May 1, 2005
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
Learning Objectives
Understand the biases that may contribute to overcalling medical errors
Describe the impact of conside…
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psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx
Spotlight
Challenging Case of Multiple Suicide Attempts in a
Complex Patient with Psychiatric Comorbidities
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - Antibiotics for URI/Sinusitis—A Simple Decision Gone
Bad
April 1, 2008
Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
Case Objectives
Understand the indications for antibiotic treatment in …
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psnet.ahrq.gov/node/33849/psn-pdf
January 01, 2018 - In Conversation With… Robert Hirschtick, MD
January 1, 2018
In Conversation With… Robert Hirschtick, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
Editor's note: Dr. Hirschtick is Associate Professor of Medicine at Northwestern Medicine, and the author
of a numbe…
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psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
January 01, 2024 - The Different Count Contributions to Retention
Differential Count Contributions in Retained Surgical Sponge Cases: Examination of Administrative Penalty
Cases from the California Department of Public Health (CDPH), Health and Safety Code Section 1280.1
Enforcement Reports from 2007-2014
A NoThing Left Behin…
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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication
Breakdown.
August 30, 2023
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
Disclosure of Relevant Financial Relationship…
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - Spotlight
Spotlight
Prolonged DKA in Pregnancy: A Case of Communication
Breakdown
Source and Credits
• This presentation is based on the August 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarah Marshall, MD and Nina M. …
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psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
August 20, 2018 - Buprenorphine and the Medically Ill Patient
Citation Text:
McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX E…
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - No News May Not Be Good News
August 1, 2012
Moore CR. No News May Not Be Good News. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
Case Objectives
Describe the frequency with which ambulatory test results are not followed up by providers.
Appreciate that inadequate follow-up of…
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - Failure to Rescue
Citation Text:
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - The Inside of a Time Out
Citation Text:
Feldman DL. The Inside of a Time Out. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
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psnet.ahrq.gov/web-mm/missing-trauma
March 03, 2011 - Missing Trauma
Citation Text:
Jurkovich GJ. Missing Trauma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/issue/human-factors-patient-safety-innovation
June 09, 2021 - Commentary
Human factors in patient safety as an innovation.
Citation Text:
Carayon P. Human factors in patient safety as an innovation. Appl Ergon. 2010;41(5):657-65. doi:10.1016/j.apergo.2009.12.011.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML E…
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psnet.ahrq.gov/issue/delivering-results
August 17, 2016 - Newspaper/Magazine Article
Delivering results.
Citation Text:
Delivering results. Landro L. Wall Street Journal. March 28, 2011.
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…
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psnet.ahrq.gov/issue/disconnected
February 03, 2011 - Commentary
Disconnected.
Citation Text:
Klass P. Disconnected. N Engl J Med. 2010;362(15):1358-61. doi:10.1056/NEJMp0911193.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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…
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psnet.ahrq.gov/issue/why-nurses-make-medication-errors-simulation-study
March 02, 2011 - Study
Why nurses make medication errors: a simulation study.
Citation Text:
Kazaoka T, Ohtsuka K, Ueno K, et al. Why nurses make medication errors: a simulation study. Nurse Educ Today. 2007;27(4):312-7.
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psnet.ahrq.gov/node/49735/psn-pdf
June 01, 2015 - First, structured diagnostic
assessments for common clinical scenarios (e.g., chest pain, fever in an
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psnet.ahrq.gov/issue/nurses-perceptions-and-experiences-communication-operating-theatre-focus-group-interview
June 22, 2009 - Study
Nurses' perceptions and experiences of communication in the operating theatre: a focus group interview.
Citation Text:
Nestel D, Kidd J. Nurses' perceptions and experiences of communication in the operating theatre: a focus group interview. BMC Nurs. 2006;5:1.
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