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psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
January 01, 2022 - TAKE HOME POINTS
38
Take-Home Points (1)
39
• Peritoneal access is the most vulnerable stage in
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - that
screening had been performed, her lung cancer would likely have
been diagnosed at an earlier stage
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psnet.ahrq.gov/node/49525/psn-pdf
December 01, 2006 - Case & Commentary: Part 1
A patient with a history of end-stage renal disease requiring hemodialysis
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psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
February 01, 2004 - tests with their parents before discharge.( 3 ) After an important test result is produced, the final stage
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psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
March 27, 2024 - Case & Commentary: Part 1
A patient with a history of end-stage renal disease requiring hemodialysis
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psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
September 01, 2012 - The second stage is: "my patients are sicker and you haven't taken that into account." … Then you get to the third stage, which is: "I'm practicing as well as I know how to already, there's
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psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
October 28, 2020 - SPOTLIGHT CASE
Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis
Citation Text:
Kuye I, Rhee C. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
October 24, 2021 - A lot of that can happen at the counseling stage, where there's some communication between the pharmacist
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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - SPOTLIGHT CASE
Right Regimen, Wrong Cancer: Patient Catches Medical Error
Citation Text:
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - means that patients are getting seen by primary care and into the health care system at an earlier stage
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
January 01, 2024 - Spotlight
Spotlight
Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head
1
Source and Credits
This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Ryan Martin, MD, FCNS and …
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psnet.ahrq.gov/node/33692/psn-pdf
February 01, 2010 - In Conversation with…Thomas J. Nasca, MD
February 1, 2010
In Conversation with…Thomas J. Nasca, MD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
Editor's note: Thomas J. Nasca, MD, is the executive director and chief executive officer of the
Accreditation Council fo…
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psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - We felt that payment in isolation might
not be sufficiently helpful—at least at that stage.
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psnet.ahrq.gov/node/857258/psn-pdf
November 30, 2023 - Always Check the Muscle Twitch: Residual
Neuromuscular Block After Removal of a Gastric Balloon
November 30, 2023
Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of
a Gastric Balloon. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/always-check-muscle-twitch-…
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psnet.ahrq.gov/node/50613/psn-pdf
October 30, 2019 - You don't have a lot of
agency when you're in the second stage of labor, which is like running the gauntlet
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psnet.ahrq.gov/node/33867/psn-pdf
October 01, 2018 - A lot of that can happen at the counseling stage, where there's some communication between the
pharmacist
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psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - Syringe Swap During Regional Block: A Case of
Medication Error and Recovery
January 31, 2024
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…
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psnet.ahrq.gov/node/33748/psn-pdf
April 01, 2013 - at the level of the initial
review by hospital-based reviewers as well as at the secondary analysis stage
-
psnet.ahrq.gov/node/33783/psn-pdf
April 01, 2015 - RW: At this stage now in the safety field, what do you see that gives you hope?
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psnet.ahrq.gov/node/49843/psn-pdf
October 01, 2018 - Spotlight: Overdiagnosis and Delay: Challenges in Sepsis
Diagnosis
October 1, 2018
Kuye I, Rhee C. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
Case Objectives
Realize the im…