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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.
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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…
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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/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.
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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.
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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/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.
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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.
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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.
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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.…