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  1. psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
    February 01, 2014 - Fewer studies have examined what types of interruptions or distractions cause actual errors in clinical
  2. psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
    September 28, 2022 - We assessed what community preferences would be for different types of services to address some of the
  3. psnet.ahrq.gov/web-mm/dropping-new-lows
    December 18, 2024 - SPOTLIGHT CASE Dropping to New Lows Citation Text: Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866578/psn-pdf
    August 28, 2024 - Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy August 28, 2024 Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insul…
  5. psnet.ahrq.gov/web-mm/delirium-or-dementia
    September 27, 2023 - SPOTLIGHT CASE Delirium or Dementia? Citation Text: Rudolph JL. Delirium or Dementia?. 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…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865884/psn-pdf
    May 29, 2024 - Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. May 29, 2024 Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49431/psn-pdf
    January 01, 2004 - Crushing Chest Pain: A Missed Opportunity January 1, 2004 Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity Case Objectives Appreciate the challenges of diagnosing aortic dissection Describe a Bayesian approach to dia…
  8. psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
    October 28, 2020 - SPOTLIGHT CASE Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis Citation Text: Kuye I, Rhee C. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
  9. 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…
  10. psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
    April 03, 2024 - SPOTLIGHT CASE Medication Reconciliation With a Twist (or Dare We Say, a Patch?) Citation Text: Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…
  11. psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
    January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx Spotlight A Loss of Trust and a Missed Diagnosis Source and Credits • This presentation is based on the February 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50613/psn-pdf
    October 30, 2019 - In Conversation With… Neel Shah, MD, MPP October 30, 2019 In Conversation With… Neel Shah, MD, MPP. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp Editor's note: Dr. Shah, MD, MPP, is an Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medi…
  13. psnet.ahrq.gov/web-mm/translating-normal-abnormal
    October 02, 2019 - SPOTLIGHT CASE Translating From Normal to Abnormal Citation Text: Turner AM. Translating From Normal to Abnormal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibT…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33855/psn-pdf
    April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM April 1, 2018 In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm Editor's note: Dr. Krumholz, Harold H. Hines, Jr. Professor of Medicine at the Yale School of Medicine and Directo…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49553/psn-pdf
    January 01, 2008 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures January 1, 2008 Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures The…
  16. 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…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33828/psn-pdf
    March 01, 2017 - In Conversation With… Mary Dixon-Woods, DPhil March 1, 2017 In Conversation With… Mary Dixon-Woods, DPhil. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil Editor's note: Dr. Dixon-Woods is RAND Professor of Health Services Research at Cambridge University and Deputy …
  18. 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…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33862/psn-pdf
    July 01, 2018 - In Conversation With… Shantanu Nundy, MD July 1, 2018 In Conversation With… Shantanu Nundy, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-shantanu-nundy-md Editor's note: Dr. Nundy is the Director of the nonprofit organization called the Human Diagnosis Project, a unique effort to cro…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849679/psn-pdf
    June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture June 28, 2023 Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/under-pressure-tracheost…

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