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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - SPOTLIGHT CASE
Crushing Chest Pain: A Missed Opportunity
Citation Text:
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx
Spotlight
Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See…
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psnet.ahrq.gov/node/33776/psn-pdf
January 01, 2015 - In Conversation With… Mark Graban, MS, MBA
January 1, 2015
In Conversation With… Mark Graban, MS, MBA. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
Editor's note: Mark Graban, MS, MBA, is an internationally recognized expert in Lean Healthcare, which
has become one of…
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psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
April 04, 2018 - SPOTLIGHT CASE
The Pains of Chronic Opioid Usage
Citation Text:
Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/nothing-called-small-surgery
February 01, 2023 - Nothing Called Small Surgery
Citation Text:
Manske C. Nothing Called Small Surgery. 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/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/perspective/conversation-withjennifer-daley-md
January 01, 2008 - We have to come up with other systems or toolkits to help them achieve standardization of systems that
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psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
September 18, 2024 - SPOTLIGHT CASE
Diagnostic Delay in the Emergency Department
Citation Text:
Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
November 02, 2016 - Promising Areas for Patient Safety Research
P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH | December 1, 2003
View more articles from the same authors.
Citation Text:
Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. …
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psnet.ahrq.gov/web-mm/deadly-duo
April 28, 2021 - The Deadly Duo
Citation Text:
Maldonado JR. The Deadly Duo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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…
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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - Falling Through the Crack (in the Bedrails)
May 1, 2016
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
Case Objectives
Review the epidemiology of patient falls and associated injuries in the hospital set…
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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.
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - SPOTLIGHT CASE
Mobility Lost in the ICU
Citation Text:
Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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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/73153/psn-pdf
April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an
Order is Not Enough
April 28, 2021
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
Disclosure of Relev…
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psnet.ahrq.gov/node/838197/psn-pdf
September 28, 2022 - Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a
Plan.
September 28, 2022
Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a Plan. PSNet [internet]. 2022.
https://psnet.…
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psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-intensive-care
October 30, 2024 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department
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February 26, 2025 - In Conversation with Jessica Behrhorst about The
Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. In Conversation with Jessica Behrhorst about The Evolution of Root Cause
Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evoluti…
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psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
January 07, 2022 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers
Citation Text:
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
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psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
April 01, 2005 - Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet)
Robert M. Wachter, MD | April 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wachter R. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Ne…