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  1. psnet.ahrq.gov/web-mm/pathologic-mistake
    February 15, 2010 - Pathologic Mistake Citation Text: Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
  2. psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
    September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization Citation Text: Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Ci…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73650/psn-pdf
    August 25, 2021 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax August 25, 2021 Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumoth…
  4. psnet.ahrq.gov/web-mm/preventable-rash
    October 01, 2012 - Preventable Rash Citation Text: McLean C. Preventable Rash. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841469/psn-pdf
    December 14, 2022 - Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. December 14, 2022 Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-mi…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72834/psn-pdf
    March 10, 2021 - Approach to Improving Patient Safety: Communication March 10, 2021 Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication Introduction Each one of the countless necessa…
  7. psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
    January 07, 2015 - Haste Makes Care Unsafe Citation Text: Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
  8. psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
    January 05, 2017 - Discontinued Medications: Are They Really Discontinued? Citation Text: Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49869/psn-pdf
    July 02, 2019 - Failure to Rescue the Mother July 2, 2019 Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/failure-rescue-mother The Case A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for vaginal bleeding. An …
  10. psnet.ahrq.gov/web-mm/fire-hole-or-fire
    August 03, 2017 - Fire in the Hole!—An OR Fire Citation Text: Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33724/psn-pdf
    February 01, 2012 - In Conversation With… Lawrence Smith, MD February 1, 2012 In Conversation With… Lawrence Smith, MD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-lawrence-smith-md Editor's note: Lawrence G. Smith, MD, is the founding Dean of Hofstra North Shore-LIJ School of Medicine and Executive Vice P…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49411/psn-pdf
    July 01, 2003 - Code Status Confusion July 1, 2003 Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/code-status-confusion Case Objectives Appreciate challenges of determining goals of care in hospitalized patients Understand patients’ common misconceptions about CPR List typical mist…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857260/psn-pdf
    November 30, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! November 30, 2023 Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/when…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49545/psn-pdf
    September 01, 2007 - Coming Undone: Failure of Closure Device September 1, 2007 Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device The Case A 65-year-old man underwent coronary angiography because of atypical exertional chest…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60952/psn-pdf
    September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac Arrest September 30, 2020 Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest Disclosure of Relevant Financial Relationships: As a pr…
  16. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
    January 01, 2022 - Spotlight Spotlight False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy Source and Credits • This presentation is based on the September 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by:…
  17. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
    June 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfer Troubles 1 2 Source and Credits This presentation is based on the June 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…
  18. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
    May 01, 2017 - PowerPoint Presentation Spotlight Diagnostic Delay in the Emergency Department 1 Source and Credits This presentation is based on the May 2017 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Kyle Marshall, MD, Geisinger Medical Center, Danv…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33864/psn-pdf
    January 01, 2019 - How Does Health Care Simulation Affect Patient Care? August 1, 2018 Lopreiato JO. How Does Health Care Simulation Affect Patient Care? PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care Perspective Introduction Health care simulation programs have spread…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33614/psn-pdf
    June 01, 2005 - Interpreting the Patient Safety Literature June 1, 2005 Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature Perspective Five years ago, a widely publicized randomized trial reported a 90% reduction in the inciden…

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