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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]. …
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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…
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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…
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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. …
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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…
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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…
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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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psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - Advancing Patient Safety Through State Reporting
Systems
June 1, 2007
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
Perspective
Seven years ago, the Institute of Medicine (I…
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psnet.ahrq.gov/node/49501/psn-pdf
February 03, 2006 - Lost in Transition
February 1, 2006
Beach C. Lost in Transition. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/lost-transition
Case Objectives
Provide an overview of transitions in continuously operating industries
Review cognitive error
Describe the complex dynamics of transitions in emergency care
Pro…
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psnet.ahrq.gov/node/49672/psn-pdf
January 01, 2013 - The Lung Nodule That Refused To Grow
December 1, 2012
Balekian AA, Gould MK. The Lung Nodule That Refused To Grow. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/lung-nodule-refused-grow
Case Objectives
Define a solitary pulmonary nodule.
Identify the different initial first steps of management.
Identify …
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - No News May Not Be Good News
August 1, 2012
Moore CR. No News May Not Be Good News. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
Case Objectives
Describe the frequency with which ambulatory test results are not followed up by providers.
Appreciate that inadequate follow-up of…
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psnet.ahrq.gov/node/60745/psn-pdf
October 01, 2020 - Multiple High-Risk Events Involving Workflow for Wasting
of Medications Used by Anesthesia
July 29, 2020
Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications
Used by Anesthesia. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-high-risk-events-involvi…
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psnet.ahrq.gov/web-mm/july-syndrome
July 01, 2011 - July Syndrome
Citation Text:
Young JQ. July Syndrome. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
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D…
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psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
November 10, 2015 - Are We Getting Better at Measuring Patient Safety?
Amy K. Rosen, PhD | November 1, 2010
View more articles from the same authors.
Citation Text:
Rosen AK. Are We Getting Better at Measuring Patient Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare R…
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - Communication Failure—Who's in Charge?
Citation Text:
Fackler J, Schwartz JM. Communication Failure—Who's in Charge?. 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/eptifibatide-epilogue
March 04, 2011 - Eptifibatide Epilogue
Citation Text:
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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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.
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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.
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - Failure to Rescue
Citation Text:
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - Spinal Epidural Abscess
Citation Text:
Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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