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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49859/psn-pdf
    April 01, 2019 - E-cigarette Explosion in a Patient Room April 1, 2019 Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room The Case A 49-year-old woman was admitted for an exacerbation of chronic obstructive pulmonary disease (COPD) without…
  2. Spotlight (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
    January 01, 2019 - Spotlight Spotlight Mistaken Attribution, Diagnostic Misstep * Source and Credits This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33865/psn-pdf
    September 01, 2018 - In Conversation With… Rebecca Lawton, PhD September 1, 2018 In Conversation With… Rebecca Lawton, PhD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd Editor's note: Rebecca Lawton, a Professor in the Psychology of Healthcare at the University of Leeds, is a health psycho…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33696/psn-pdf
    June 01, 2010 - In Conversation with…Pat Croskerry, MD, PhD June 1, 2010 In Conversation with…Pat Croskerry, MD, PhD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd Editor's note: Pat Croskerry, MD, PhD, is a professor in emergency medicine at Dalhousie University in Halifax, Nova…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49450/psn-pdf
    June 01, 2004 - The Wrong Shot: Error Disclosure June 1, 2004 Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure Case Objectives Describe the rationale for disclosing harmful errors to patients. Describe the specific information that patie…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49654/psn-pdf
    June 01, 2012 - Transfer Troubles June 1, 2012 Hains IM. Transfer Troubles. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfer-troubles Case Objectives Recognize that transfer of patients between hospitals is common. Understand the frequency of errors and adverse events in the transfer of patients between hospitals. …
  7. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
    September 01, 2014 - PowerPoint Presentation Spotlight A Lot of Pain (Medications) 1 This presentation is based on the September 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Shoshana J. Herzig, MD, MPH, Division of General Medicine, Beth Israel Deaconess Medic…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33744/psn-pdf
    February 01, 2013 - In Conversation With… Beverley H. Johnson February 1, 2013 In Conversation With… Beverley H. Johnson. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson Editor's note: Beverley H. Johnson is the President and Chief Executive Officer of the Institute for Patient- and Family-…
  9. psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx Spotlight Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49485/psn-pdf
    August 29, 2024 - Blind Spot June 1, 2005 Lee LA. Blind Spot. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/blind-spot The Case A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842923/psn-pdf
    February 01, 2023 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. February 1, 2023 Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. PSNet [internet]. …
  12. psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
    August 30, 2023 - Annual Perspective Impact of System Failures on Healthcare Workers George Zangaro, PhD, RN, FAAN, Cindy Manaoat Van, MHSA, Sarah Mossburg, RN, PhD | March 21, 2023  View more articles from the same authors. Citation Text: Zangaro G, Van CM, Mossburg S. Imp…
  13. psnet.ahrq.gov/web-mm/low-totem-pole
    October 01, 2003 - SPOTLIGHT CASE Low on the Totem Pole Citation Text: Wachter R. Low on the Totem Pole. 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 …
  14. psnet.ahrq.gov/web-mm/failure-rescue-mother
    September 23, 2020 - Failure to Rescue the Mother Citation Text: Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. 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…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33875/psn-pdf
    March 01, 2019 - In Conversation With… Susan Haas, MD, MSc March 1, 2019 In Conversation With… Susan Haas, MD, MSc. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc Editor's note: Dr. Haas is an obstetrician–gynecologist and co-Principal Investigator for Ariadne Labs' work focused on health…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852808/psn-pdf
    August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication Breakdown. August 30, 2023 Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown Disclosure of Relevant Financial Relationship…
  17. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
    January 01, 2023 - Spotlight Spotlight Prolonged DKA in Pregnancy: A Case of Communication Breakdown Source and Credits • This presentation is based on the August 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Sarah Marshall, MD and Nina M. …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49573/psn-pdf
    January 01, 2009 - Dangerous Shift November 1, 2008 Patterson ES. Dangerous Shift. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dangerous-shift Case Objectives Review the evidence base on erroneous actions related to shift changes. Understand the limits of standardizing handoffs in preventing errors at shift change. Expla…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49819/psn-pdf
    February 01, 2018 - Signout Fallout February 1, 2018 Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/signout-fallout Case Objectives Understand the role of communication failures in medical errors and preventable adverse events. Review the evidence in support of handoff improvement pr…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49760/psn-pdf
    May 01, 2016 - Mismanagement of Delirium May 1, 2016 Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/mismanagement-delirium The Case An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional ho…

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