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psnet.ahrq.gov/issue/impact-transitioning-24-hour-16-hour-call-model-amongst-cohort-canadian-anesthesia-residents
June 03, 2020 - Study
The impact of transitioning from a 24-hour to a 16-hour call model amongst a cohort of Canadian anesthesia residents at McMaster University—a survey study.
Citation Text:
Sussman D, Paul JE. The impact of transitioning from a 24-hour to a 16-hour call model amongst a cohort of Cana…
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psnet.ahrq.gov/issue/organizational-learning-and-patient-safety-hospital-pharmacy-settings
September 23, 2020 - Study
Organizational learning and patient safety: hospital pharmacy settings.
Citation Text:
Abdallah W, Johnson C, Nitzl C, et al. Organizational learning and patient safety: hospital pharmacy settings. J Health Organ Manag. 2019;33(6):695-713. doi:10.1108/JHOM-11-2018-0319.
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psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
October 01, 2011 - SPOTLIGHT CASE
Abdominal Aortic Aneurysm Screening
Citation Text:
Jim J. Abdominal Aortic Aneurysm Screening. 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/web-mm/urinary-retention-dilemma
March 01, 2013 - Urinary Retention Dilemma
Citation Text:
Joseph AC. Urinary Retention Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - One Bronchoscopy, Two Errors
Citation Text:
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. 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/sick-and-pregnant
August 25, 2021 - Sick and Pregnant
Citation Text:
El-Ibiary S. Sick and Pregnant. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - Failure to Latch
September 1, 2008
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/failure-latch
The Case
The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to
breastfeeding exclusively for 6 months. However, early br…
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psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
February 20, 2019 - Emerging Safety Issues in Artificial Intelligence
Robert Challen, MA, MBBS | July 1, 2019
View more articles from the same authors.
Citation Text:
Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. Rockville (MD): Agency for Healthcare…
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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - Spotlight
Spotlight
False Assumptions Result in a Missed
Pneumothorax after Bronchoscopy with
Transbronchial Biopsy
Source and Credits
• This presentation is based on the September 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by:…
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psnet.ahrq.gov/web-mm/over-counter-oversight
March 21, 2009 - Over-the-Counter Oversight
Citation Text:
Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. 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/dropped-no
October 30, 2019 - The Dropped "No"
Citation Text:
Johnson AJ. The Dropped "No". 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/node/49440/psn-pdf
March 01, 2004 - Autopsy Revelation
March 1, 2004
Shojania KG. Autopsy Revelation. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/autopsy-revelation
The Case
A 45-year-old male with development delay presented to the emergency department with acute abdominal
pain. His mother, who was his main caregiver, accompanied him. Th…
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psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and
Umpires Have in Common?
February 1, 2007
Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? PSNet
[internet]. 2007.
https://psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
Perspectiv…
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psnet.ahrq.gov/web-mm/fire-hole-or-fire
August 03, 2017 - Fire in the Hole!—An OR Fire
Citation Text:
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. 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/node/846770/psn-pdf
March 29, 2023 - Procedure Complications – Who is Responsible for
Follow up?
March 29, 2023
Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up? PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
The Case
A 74-year-old man with newly diagnose…
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psnet.ahrq.gov/node/49544/psn-pdf
September 01, 2007 - Discharging Our Responsibility
September 1, 2007
Fonarow GC. Discharging Our Responsibility. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/discharging-our-responsibility
The Case
A 75-year-old man with a history of hypertension, coronary artery disease, and congestive heart failure
(CHF) presented to the …
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psnet.ahrq.gov/node/49612/psn-pdf
November 01, 2010 - Treatment Challenges After Discharge
November 1, 2010
Coffey C. Treatment Challenges After Discharge. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
Case Objectives
Understand types and frequencies of adverse events occurring between patient discharge from the
hospital …
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - Medical Devices in the "Wild"
Citation Text:
Gurses AP, Doyle PA. Medical Devices in the "Wild". 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/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Acute Respiratory Arrest in Pregnancy
Citation Text:
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/49497/psn-pdf
December 01, 2005 - Slippery Slide Into Life
December 1, 2005
Halamek LP. Slippery Slide Into Life. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/slippery-slide-life
The Case
A 25-year-old woman presented to the hospital in labor and at full gestation after receiving uncomplicated
prenatal care. A third-year obstetrics and g…