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  1. psnet.ahrq.gov/web-mm/another-fall
    June 01, 2010 - SPOTLIGHT CASE Another Fall Citation Text: Bogardus SG. Another Fall. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
  2. psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
    September 25, 2019 - SPOTLIGHT CASE Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. Citation Text: Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research …
  3. psnet.ahrq.gov/curated-library/value-and-patient-safety
    October 30, 2019 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Value and Patient Safety  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Tea…
  4. psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
    November 03, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Implementation of Patient Safety Projects  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybraria…
  5. psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
    September 16, 2015 - SPOTLIGHT CASE Which Line: Ordering Provider or Proceduralist? Citation Text: Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49392/psn-pdf
    April 01, 2003 - Another Fall April 1, 2003 Bogardus SG. Another Fall. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/another-fall Case Objectives List risk factors for falls in hospitalized patients Understand appropriate use of restraints Identify system issues contributing to falls in hospitalized patients Case & Comm…
  7. 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. Copy Citation Format: …
  8. psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
    September 30, 2020 - SPOTLIGHT CASE Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Citation Text: Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. Rockville (MD): Agency for Healt…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72589/psn-pdf
    December 23, 2020 - Delayed Breast Cancer Diagnosis: A False Sense of Security. December 23, 2020 Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security The Case A 60-year-old woman was se…
  10. 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. Copy Citation Format: …
  11. psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
    February 01, 2004 - SPOTLIGHT CASE Delay in Treatment: Failure to Contact Patient Leads to Significant Complications Citation Text: Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departmen…
  12. psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
    February 26, 2025 - In Conversation With… Sidney Dekker, MA, MSc, PhD September 1, 2013  Citation Text: In Conversation With… Sidney Dekker, MA, MSc, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Co…
  13. psnet.ahrq.gov/web-mm/nothing-called-small-surgery
    February 01, 2023 - Nothing Called Small Surgery Citation Text: Manske C. Nothing Called Small Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840256/psn-pdf
    November 16, 2022 - In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD November 16, 2022 In Conversation With.. Pascale Carayon, PhD and Nicole Werner, PhD. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd Editor’s note: Dr. Pascale Carayon, PhD, is a p…
  15. psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx Spotlight Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes Source and Credits • This presentation is based on the April 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/we…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73906/psn-pdf
    October 06, 2021 - In Conversation With….Alison Stuebe, MD, MSc and Kristin Tully, PhD October 6, 2021 In Conversation With….Alison Stuebe, MD, MSc and Kristin Tully, PhD. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd Editor’s Note: Alison Stuebe, MD, MSc, is a…
  17. psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
    March 07, 2018 - SPOTLIGHT CASE Too Many Cooks in the Kitchen Citation Text: Dutton RP. Too Many Cooks in the Kitchen. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote X…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49564/psn-pdf
    July 01, 2008 - Dependence vs. Pain July 1, 2008 Gordon AJ. Dependence vs. Pain . PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dependence-vs-pain Case Objectives Define opioid dependence and opioid withdrawal syndrome. Describe the treatment of opioid withdrawal syndrome including the use of the Clinical Opioid Withdra…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73128/psn-pdf
    July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. April 7, 2021 https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications- and-enhances Summary The Hospital at Homesm program provides hospital-level care…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72911/psn-pdf
    March 15, 2021 - The Impact of Communication on Medication Errors March 15, 2021 Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors The Case   A 93-year-old man with a history of chronic systolic heart failure…

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