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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/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/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/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/sites/default/files/import/webmm.ahrq.gov.45_slideshow.ppt
January 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case January 2004
Crushing Chest Pain:
A Missed Opportunity
Source and Credits
This presentation is based on the Jan. 2004
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Mark Grabe…
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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/node/866993/psn-pdf
October 30, 2024 - In Conversation with Elizabeth Salisbury-Afshar about
Harm Reduction Strategies to Improve Safety for People
Who Use Substances
October 30, 2024
Salisbury-Afshar E, Gale B, Mossburg S. In Conversation with Elizabeth Salisbury-Afshar about Harm
Reduction Strategies to Improve Safety for People Who Use Substances. P…
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - SPOTLIGHT CASE
Spotlight: Mistaken Attribution, Diagnostic Misstep
Citation Text:
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citat…
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psnet.ahrq.gov/node/865373/psn-pdf
March 27, 2024 - In Conversation with...Patrick Tighe about Artificial
Intelligence
March 27, 2024
Tighe P. In Conversation with..Patrick Tighe about Artificial Intelligence . PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
Editor's note: Patrick Tighe, MD, MS…
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psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
November 01, 2006 - In Conversation With...Donald A. Norman, PhD
November 1, 2006
Also Read an Essay
Citation Text:
In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006.In Conversation With...Donald A. Norman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthca…
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psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
November 18, 2016 - SPOTLIGHT CASE
Adolescent Diabetes: A Routine Visit?
Citation Text:
Slap GB. Adolescent Diabetes: A Routine Visit?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
Copy Citation
Format:
Google Scholar Bi…
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psnet.ahrq.gov/node/60858/psn-pdf
August 26, 2020 - When the Meds Don’t Reach the Bed
August 26, 2020
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
The Case
A 69-year-old man with cognitive impairment and marginal housing was admitted for acute exacerbation of
chronic obs…
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psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd
November 01, 2017 - In Conversation With… Wanda Pratt, PhD
November 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Wanda Pratt, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Cop…
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - In Conversation With… Mark L. Graber, MD
January 1, 2016
In Conversation With… Mark L. Graber, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
Editor's note: Dr. Graber is a Senior Fellow at RTI International and Professor Emeritus of Medicine at
the State University o…
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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/primer/maternal-safety
January 10, 2024 - Maternal Safety
Citation Text:
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
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psnet.ahrq.gov/web-mm/impact-communication-medication-errors
August 01, 2009 - The Impact of Communication on Medication Errors
Citation Text:
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citation
Format:
…
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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/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety
Ronen Rozenblum, MD, MPH, and David Bates, MD, MS | November 1, 2017
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Rozenblum R, Bates DW. The Role…