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psnet.ahrq.gov/node/33651/psn-pdf
June 01, 2007 - In Conversation with...Diane Rydrych, MA
June 1, 2007
In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
Editor's Note: Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota
Department of Health,…
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psnet.ahrq.gov/node/49397/psn-pdf
May 01, 2003 - The Dropped Lung
May 1, 2003
Heffner JR. The Dropped Lung. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dropped-lung
The Case
A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been
hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…
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psnet.ahrq.gov/node/49538/psn-pdf
June 01, 2007 - Abnormal Volunteer Results
June 1, 2007
Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results
The Case
A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent
magnetic resonance imaging (MRI) of her abdo…
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psnet.ahrq.gov/node/860049/psn-pdf
January 04, 2024 - Myasthenia Crisis after a Delayed Diagnosis in a
Medically Complex Patient.
January 4, 2024
Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. PSNet [internet].
2024.
https://psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
The Case
A 9…
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psnet.ahrq.gov/node/33881/psn-pdf
August 01, 2019 - In Conversation With… Erik Hollnagel, PhD
June 1, 2019
In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
Editor's note: Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden)
as well as Visiting…
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psnet.ahrq.gov/node/33775/psn-pdf
December 01, 2014 - African Partnerships for Patient Safety: Lessons Learned
December 1, 2014
Syed SS. African Partnerships for Patient Safety: Lessons Learned. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
Perspective
In the last 6 years I have had the privilege of sha…
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psnet.ahrq.gov/node/49837/psn-pdf
August 01, 2018 - Abdominal Aortic Aneurysm Screening
August 1, 2018
Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
Case Objectives
Describe risk factors associated with abdominal aortic aneurysm.
Identify patient populations meeting criteria fo…
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psnet.ahrq.gov/node/73999/psn-pdf
October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in
the Operating Room
October 27, 2021
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.140_slideshow.ppt
December 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case December 2006
Hidden Heparins: HIT Happens
Source and Credits
This presentation is based on the December 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Patrick F. Fogarty,…
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psnet.ahrq.gov/node/49569/psn-pdf
September 01, 2008 - Where's the Feeding Tube?
September 1, 2008
Metheny NA, Meert KL. Where's the Feeding Tube? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wheres-feeding-tube
The Case
A 13-year-old boy was involved in a motor vehicle collision and experienced a traumatic brain injury.
Because of the injuries, he was unabl…
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psnet.ahrq.gov/node/49618/psn-pdf
February 01, 2011 - tests to see if the patient's pancytopenia was preexisting or due to the
medications; and (iv) no 12-week … Moreover, when the patient was found to
have pancytopenia, interferon was decreased to every other week
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psnet.ahrq.gov/web-mm/bleeding-risk
November 01, 2003 - September 1, 2003
WebM&M Cases
The 2-Week Itch
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psnet.ahrq.gov/Webmm/submit-case-info
August 10, 2025 - Selection Criteria and Honorarium Information
How it works
Health care professionals may submit de-identified cases that highlight medical errors or other patient
safety/quality
issues. Note that you can choose to submit cases either …
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psnet.ahrq.gov/node/73335/psn-pdf
May 26, 2021 - psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
The Case
A 4-year-old (former 33-week
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psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - tests to see if the patient's pancytopenia was preexisting or due to the medications; and (iv) no 12-week … Moreover, when the patient was found to have pancytopenia, interferon was decreased to every other week
-
psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
March 27, 2024 - SPOTLIGHT CASE
Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head
Citation Text:
Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-42
September 26, 2017 - Commentary
ISMP medication error report analysis.
Citation Text:
Cohen MR, Smetzer JL. Oral Syringes: A Crucial and Economical Risk-Reduction Strategy that has Not Been Fully Utilized; Caution regarding Once-Weekly Levothyroxine; When Drug Strengths Differ by 10-Fold; Lower Colchicine Do…
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psnet.ahrq.gov/node/49704/psn-pdf
March 01, 2014 - Late Anemia Following Rh Disease in a Newborn
March 1, 2014
Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
The Case
A full-term neonate was delivered uneventfully to an Rh-negative woman who had re…
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psnet.ahrq.gov/node/49407/psn-pdf
July 01, 2003 - Bleeding Risk
July 1, 2003
Crowther MA. Bleeding Risk. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/bleeding-risk
The Case
A frail 78-year-old woman fell at home and fractured her left hip. Her past medical history included atrial
fibrillation, hypertension, coronary artery disease, and stroke. The surgi…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.182_slideshow.ppt
September 01, 2008 - Spotlight Case July 2008
Spotlight Case
Empiric Steroids: the Good, the Bad, and the Ugly
Source and Credits
This presentation is based on the September 2008 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Edward D. Harris, Jr, MD, Stanford U…