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  1. Psn-Pdf (pdf file)

    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,…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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 …
  9. 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,…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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
  12. psnet.ahrq.gov/web-mm/bleeding-risk
    November 01, 2003 - September 1, 2003 WebM&M Cases The 2-Week Itch
  13. 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 …
  14. Psn-Pdf (pdf file)

    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
  15. 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
  16. 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 …
  17. 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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. 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…

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