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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - SPOTLIGHT CASE
Don't Dismiss the Dangerous: Obstetric Hemorrhage
Citation Text:
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed
June 01, 2017 - The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed?
Vanessa K. Martin, DO, MS; Nasim Mirnateghi, PhD; and Mahdi Khoshchehreh, MD, MS | June 1, 2017
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Martin …
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psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
January 29, 2021 - An Incomplete Anesthesia History Leads to Adverse Outcomes
Citation Text:
Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/33878/psn-pdf
April 01, 2019 - In Conversation With… … Jennifer Schulz Moore, LLB,
MA, PhD
April 1, 2019
In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd
Editor's note: Dr. Schulz Moore is the Director of Learning and Teaching at…
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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - Delayed Diagnosis of Mesenteric Ischemia
August 31, 2022
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for…
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psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
June 01, 2017 - In Conversation With… Paul Aylin, MBChB
June 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Paul Aylin, MBChB. 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/node/33686/psn-pdf
August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS
August 1, 2009
In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
Editor's note: Steven Spear, DBA, MS, MS, is Senior Lecturer at Massachusetts Institute of Tech…
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psnet.ahrq.gov/node/33752/psn-pdf
August 01, 2013 - In Conversation With… J. Bryan Sexton, PhD, MA
August 1, 2013
In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
Editor's note: J. Bryan Sexton, PhD, is associate professor and director of the Patient Safety Center for
the D…
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psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - In Conversation With… Mark Chassin, MD, MPP, MPH
April 1, 2017
In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
Editor's note: Dr. Chassin is president and chief executive officer of The Joint Commission. He is also
p…
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation
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August 30, 2023
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psnet.ahrq.gov/node/72613/psn-pdf
December 22, 2020 - In Conversation With... Elsabeth Kalenderian, DDS, MPH,
PhD and Muhammad F. Walji, PhD
December 22, 2020
In Conversation With.. Elsabeth Kalenderian, DDS, MPH, PhD and Muhammad F. Walji, PhD. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-
w…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - SPOTLIGHT CASE
Delayed Diagnosis of Mesenteric Ischemia
Citation Text:
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
June 24, 2020 - These dose adjustments were recommended or endorsed by a team that included surgeons, nurses, and pharmacists
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psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
August 01, 2010 - Australia developed a national safety education framework.( 24 ) In late 2005, the American College of Surgeons
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psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
August 01, 2010 - Australia developed a national safety education framework.( 24 ) In late 2005, the American College of Surgeons
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psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
March 01, 2015 - In Conversation With… Brian Jarman, PhD
March 1, 2015
Also Read an Essay
Citation Text:
In Conversation With… Brian Jarman, PhD. 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/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx
Spotlight
A Missed Bowel Perforation – the Importance of
Diagnostic Reasoning
Source and Credits
• This presentation is based on the September 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/web…
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psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
April 26, 2023 - In Conversation With… Mark Chassin, MD, MPP, MPH
April 1, 2017
Citation Text:
In Conversation With… Mark Chassin, MD, MPP, MPH. 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/conversation-gordon-schiff-md
February 26, 2025 - In Conversation With… Gordon Schiff, MD
July 1, 2018
Citation Text:
In Conversation With… Gordon Schiff, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - Intubation Mishap
September 1, 2003
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/intubation-mishap
Case Objectives
To understand and apply a structured method of human factors case analysis
To describe the key components of effective teamwork
To understand the imp…