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  1. psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
    September 01, 2016 - SPOTLIGHT CASE Multifactorial Medication Mishap Citation Text: Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNot…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74121/psn-pdf
    November 30, 2021 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. November 30, 2021 Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emerg…
  3. 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. Copy …
  4. psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
    November 13, 2024 - Delayed Diagnosis of Endocrinologic Emergencies Citation Text: Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google …
  5. psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
    December 01, 2014 - SPOTLIGHT CASE Not-So-Therapeutic Tap Citation Text: Barsuk JH. Not-So-Therapeutic Tap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49611/psn-pdf
    October 01, 2010 - The Deadly Duo October 1, 2010 Maldonado JR. The Deadly Duo. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/deadly-duo The Case A 29-year-old man with a history of depression and possible psychosis was found unconscious and unresponsive at home and was brought to the emergency department. He was tachycardi…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33688/psn-pdf
    October 01, 2009 - In Conversation with... Charles Ornstein October 1, 2009 In Conversation with.. Charles Ornstein . PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-charles-ornstein Editor's note: Charles Ornstein is a senior reporter at ProPublica, a nonprofit news organization in New York. Formerly with th…
  8. psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx Spotlight Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861760/psn-pdf
    January 31, 2024 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery January 31, 2024 Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49657/psn-pdf
    July 01, 2012 - Not-So-Therapeutic Tap July 1, 2012 Barsuk JH. Not-So-Therapeutic Tap. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/not-so-therapeutic-tap Case Objectives Describe current issues with training clinicians to perform procedures. Understand how simulation can be used to ensure trainees are competent in proc…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49750/psn-pdf
    January 01, 2016 - A Room Without Orders January 1, 2016 Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/room-without-orders Case Objectives Review a common process for planned direct hospital admissions. Describe challenges of prioritizing day-to-day patient care activities wi…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33692/psn-pdf
    February 01, 2010 - In Conversation with…Thomas J. Nasca, MD February 1, 2010 In Conversation with…Thomas J. Nasca, MD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md Editor's note: Thomas J. Nasca, MD, is the executive director and chief executive officer of the Accreditation Council fo…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33793/psn-pdf
    November 01, 2015 - In Conversation With… Kaveh Shojania, MD November 1, 2015 In Conversation With… Kaveh Shojania, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md Editor's note: Kaveh Shojania, MD, is Editor-in-Chief of BMJ Quality and Safety and Director of the Centre for Quality Impro…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49525/psn-pdf
    December 01, 2006 - Hidden Heparins: HIT Happens December 1, 2006 Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens Case Objectives Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication, thrombosis. Discuss the managem…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33706/psn-pdf
    February 01, 2011 - In Conversation with...Brent C. James, MD, MStat February 1, 2011 In Conversation with..Brent C. James, MD, MStat. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat Editor's note: Brent C. James, MD, MStat, is Chief Quality Officer and Executive Director of the Insti…
  16. 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 Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL August 30, 2023 View more articles from the…
  17. psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
    February 01, 2007 - SPOTLIGHT CASE Crushing Chest Pain: A Missed Opportunity Citation Text: Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google …
  18. psnet.ahrq.gov/web-mm/dissecting-presentation
    May 05, 2021 - SPOTLIGHT CASE Dissecting the Presentation Citation Text: Suat-Ooi SB. Dissecting the Presentation. 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 …
  19. psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
    December 02, 2020 - SPOTLIGHT CASE The Lost Start Date: an Unknown Risk of E-prescribing Citation Text: Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cit…
  20. psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
    May 26, 2021 - “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records Citation Text: MacDonald S. “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…

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