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psnet.ahrq.gov/node/49548/psn-pdf
October 01, 2007 - Toxic Tachycardia
October 1, 2007
Wartofsky L. Toxic Tachycardia. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/toxic-tachycardia
The Case
A 66-year-old woman with a past medical history of hypertension and breast cancer was admitted with
abdominal pain. She complained of 3 weeks of progressive severe rig…
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psnet.ahrq.gov/node/841468/psn-pdf
December 14, 2022 - Don’t Bite Your Tongue.
December 14, 2022
Singh NS. Don’t Bite Your Tongue. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/dont-bite-your-tongue
The Case
A 63-year-old woman with a past medical history of hypertension, osteoarthritis, migraine headaches, and
daily smoking was admitted to a hospital for ant…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - PowerPoint Presentation
Spotlight Case
Multifactorial Medication Mishap
1
This presentation is based on the February 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Annie Yang, PharmD, BCPS
NYU Langone Medical Center
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/node/49867/psn-pdf
July 02, 2019 - Diuretics and Electrolyte Abnormalities
July 2, 2019
Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
Case Objectives
Recognize that thiazide diuretics can lead to serious adverse events.
State how commonly used t…
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psnet.ahrq.gov/node/49590/psn-pdf
January 01, 2010 - Is the Admission Drug Dose Too Low?
August 1, 2009
Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
The Case
A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to
the hospit…
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psnet.ahrq.gov/node/49839/psn-pdf
August 01, 2018 - Mixup Beyond the Medication Label
August 1, 2018
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
The Case
An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another
hospi…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
August 01, 2015 - PowerPoint Presentation
Spotlight
Privacy or Safety?
1
This presentation is based on the July/August 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John D. Halamka, MD, MS, Beth Israel Deaconess Medical Center; and Deven McGraw, JD, MPH, LLM…
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psnet.ahrq.gov/node/49697/psn-pdf
December 01, 2013 - Check the Anesthesia Machine
December 1, 2013
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/check-anesthesia-machine
The Case
A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension,
diabetes, sleep apnea…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.230_slideshow.ppt
December 01, 2010 - Spotlight Case July 2008
Spotlight Case
The Forgotten Turn
*
*
Source and Credits
This presentation is based on the December 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Susan Barbour, RN, FNP, University of California San Francisco …
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psnet.ahrq.gov/Webmm/submit-case-info
August 10, 2025 - Selection Criteria and Honorarium Information
How it works
Health care professionals may submit de-identified cases that highlight medical errors or other patient
safety/quality
issues. Note that you can choose to submit cases either …
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psnet.ahrq.gov/node/843736/psn-pdf
February 01, 2023 - Saved by ECMO
February 1, 2023
Weiss NA. Saved by ECMO . PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/saved-ecmo
The Case
A 27-year-old pregnant woman was admitted at an estimated gestational age (EGA) of 29 weeks for
increased shortness of breath. She was diagnosed with severe pulmonary arterial hyperte…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.287_slideshow.ppt
December 01, 2012 - Spotlight Case July 2008
Spotlight Case
The Lung Nodule That Refused To Grow
*
*
Source and Credits
This presentation is based on the December 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Alex A. Balekian, MD, MSHS, Keck School of Med…
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psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
January 01, 2014 - Annual Perspective
Computerized Provider Order Entry and Patient Safety
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015
View more articles from the same authors.
Citation Text:
Sarkar U, Shojania KG. Computerized Provider Order Entry and Patien…
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psnet.ahrq.gov/node/866265/psn-pdf
July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to
Medication Error During Patient Transport
July 31, 2024
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During
Patient Transport. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…
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psnet.ahrq.gov/perspective/accountability-patient-safety
January 01, 2018 - Annual Perspective
Accountability in Patient Safety
Christopher Moriates, MD, and Robert M. Wachter, MD | January 1, 2015
View more articles from the same authors.
Citation Text:
Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. Rock…
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psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis
Patrice Spath, BA, RHIT, and William Minogue, MD | July 1, 2008
View more articles from the same authors.
Citation Text:
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause …
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - A Stroke of Error
December 1, 2014
Barrett KM. A Stroke of Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/stroke-error
Case Objectives
State the key clinical factors to assess in a patient with suspected stroke.
Appreciate the relationship between elevated blood pressure and stroke in the acute sett…
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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/web-mm/need-eat
February 10, 2021 - The Need to Eat
Citation Text:
Widaman AM. The Need to Eat. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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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…