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  1. psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
    July 01, 2012 - EMR Entry Error: Not So Benign Citation Text: Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
  2. psnet.ahrq.gov/web-mm/weighty-mistake
    September 01, 2016 - SPOTLIGHT CASE A Weighty Mistake Citation Text: Bokser SJ. A Weighty Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
  3. psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
    November 16, 2022 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. Citation Text: Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.. PSNet [inter…
  4. psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
    May 01, 2018 - SPOTLIGHT CASE Medication Reconciliation: Whose Job Is It? Citation Text: Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Googl…
  5. psnet.ahrq.gov/web-mm/elopement
    July 14, 2010 - SPOTLIGHT CASE Elopement Citation Text: Gerardi D. Elopement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
  6. psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
    November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures Citation Text: Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49690/psn-pdf
    September 01, 2013 - The Pains of Chronic Opioid Usage September 1, 2013 Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage Case Objectives Describe the appropriate initial assessment of patients with chronic non-cancer pain. List the most comm…
  8. psnet.ahrq.gov/web-mm/errors-sepsis-management
    November 03, 2015 - SPOTLIGHT CASE Errors in Sepsis Management Citation Text: Shimabukuro D. Errors in Sepsis Management. 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 X…
  9. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
    January 01, 2022 - Spotlight Spotlight Delayed Diagnosis of Mesenteric Ischemia Source and Credits • This presentation is based on the August 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: Anamaria Robles, MD, and Garth Utter, MD, MSc o AHRQ WebM&M…
  10. psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
    February 26, 2025 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL January …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74691/psn-pdf
    January 01, 2021 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument January 26, 2022 https://psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor- college-medicine Summary The Revised Safer Dx Instr…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33732/psn-pdf
    July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP July 1, 2012 In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp Editor's note: David Blumenthal, MD, MPP, is Chief Health Information and Innovation Officer, Partners Healt…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49771/psn-pdf
    July 01, 2016 - Unintended Consequences of CPOE October 1, 2016 Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe Case Objectives Explain how technology, including computerized provider order entry, can transform, rather than eliminate, hazards. Recogni…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49388/psn-pdf
    February 01, 2003 - Unexplained Apnea Under Anesthesia February 1, 2003 Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia Case Objectives Clinical Objectives List the causes of prolonged apnea in the operating room Describe the steps in management …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49855/psn-pdf
    March 01, 2019 - Which Line: Ordering Provider or Proceduralist? March 1, 2019 Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist Case Objectives Review the role of mistake-proofing to block errors from leading to adverse…
  16. psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd
    February 26, 2025 - In Conversation With… Paul G. Shekelle, MD, MPH, PhD October 1, 2011  Citation Text: In Conversation With… Paul G. Shekelle, MD, MPH, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862983/psn-pdf
    February 28, 2024 - Airway Obstruction during Anterior Cervical Spine Surgery February 28, 2024 Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery The Case A 47-year-old obese man (body weight 13…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33734/psn-pdf
    August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD August 1, 2012 In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd Editor's note: The topic of patient safety in long-term care facilities has not received the attent…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33843/psn-pdf
    October 01, 2017 - In Conversation With… Jeffrey Starke, MD October 1, 2017 In Conversation With… Jeffrey Starke, MD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-jeffrey-starke-md Editor's note: Dr. Starke is Professor of Pediatrics–Infectious Disease at Baylor College of Medicine and served as Infection…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73336/psn-pdf
    May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers May 26, 2021 Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers The Case  …

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