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psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - Again, that’s something we like to help organizations do; it is a skill set you can develop and use.
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psnet.ahrq.gov/web-mm/neurological-red-flags-missed-stroke-after-intermittent-episodes-dizziness-and-headache
February 08, 2023 - It requires some tactile skill and learning.
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psnet.ahrq.gov/sites/default/files/2024-11/spotlight_case_neurological_red_flags_final.pptx
January 01, 2024 - It requires some tactile skill and learning.
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psnet.ahrq.gov/node/867206/psn-pdf
December 18, 2024 - It requires
some tactile skill and learning.
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psnet.ahrq.gov/node/843051/psn-pdf
February 01, 2023 - Respiratory Distress after Neck Surgery: Two Cases of
Postoperative Cervical Hematoma.
February 1, 2023
Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical
Hematoma. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-…
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…
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psnet.ahrq.gov/node/838221/psn-pdf
September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH
September 28, 2022
In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
Editor’s Note: Freya Spielberg, MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social
enterp…
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psnet.ahrq.gov/node/33791/psn-pdf
September 01, 2015 - In Conversation With… Vineet Arora, MD, MAPP
September 1, 2015
In Conversation With… Vineet Arora, MD, MAPP. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
Editor's note: Vineet Arora, MD, MAPP, is Director of GME Clinical Learning Environment Innovation,
Associate Pr…
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psnet.ahrq.gov/node/60267/psn-pdf
March 01, 2021 - Affordable Housing Community Offers Seniors Onsite
Health Care Coordination and Support, Reducing Hospital
Admissions and Falls and Improving Resident Health
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-h…
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psnet.ahrq.gov/node/33789/psn-pdf
August 01, 2015 - In Conversation With… Robert M. Wachter, MD
August 1, 2015
In Conversation With… Robert M. Wachter, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
Editor's note: Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF,
where he also …
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - Spotlight
Spotlight
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
1
Source and Credits
This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Samantha Brown…
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - SPOTLIGHT CASE
What Happened on Telemetry?
Citation Text:
Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNo…
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psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
September 27, 2023 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.
Citation Text:
Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depa…
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psnet.ahrq.gov/web-mm/pill-organizing-plight
June 19, 2018 - SPOTLIGHT CASE
A Pill Organizing Plight
Citation Text:
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTe…
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - The Impact of Communication on Medication Errors
March 15, 2021
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors
The Case
A 93-year-old man with a history of chronic systolic heart failure…
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - SPOTLIGHT CASE
Getting to the Root of the Matter
Citation Text:
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Schola…
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psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
March 27, 2024 - SPOTLIGHT CASE
"Do You Want Everything Done?": Clarifying Code Status
Citation Text:
Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. 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/node/846975/psn-pdf
March 28, 2023 - In Conversation with... Christie Allen about Maternal
Safety and Perinatal Mental Health
March 28, 2023
In Conversation with.. Christie Allen about Maternal Safety and Perinatal Mental Health. PSNet [internet].
2023.
https://psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal…
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psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
May 31, 2023 - In Conversation With… Vineet Arora, MD, MAPP
September 1, 2015
Citation Text:
In Conversation With… Vineet Arora, MD, MAPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citatio…
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…