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psnet.ahrq.gov/web-mm/dissecting-presentation
May 05, 2021 - SPOTLIGHT CASE
Dissecting the Presentation
Citation Text:
Suat-Ooi SB. Dissecting the Presentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
November 16, 2022 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures
Citation Text:
Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
May 19, 2021 - SPOTLIGHT CASE
Postdischarge Follow-Up Phone Call
Citation Text:
Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - SPOTLIGHT CASE
The Perils of Cross Coverage
Citation Text:
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - In Conversation With… Tejal K. Gandhi, MD, MPH
April 1, 2014
Citation Text:
In Conversation With… Tejal K. Gandhi, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
June 15, 2022 - SPOTLIGHT CASE
Anchoring Bias With Critical Implications
Citation Text:
Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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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…
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psnet.ahrq.gov/perspective/suicide-prevention
March 24, 2025 - Suicide Prevention
Edwin Boudreaux, PhD; Bryan Gale, MA; Sarah Mossburg, PhD | March 25, 2025
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Boudreaux E, Gale B, Mossburg SE. Suicide Prevention. PSNet [internet]. Rockville (…
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psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention
March 25, 2025 - In Conversation with Edwin Boudreaux about Suicide Prevention
Edwin Boudreaux, PhD; Bryan Gale, MA; Sarah Mossburg, Phd | March 24, 2025
Also Read the Essay
View more articles from the same authors.
Citation Text:
Boudreaux E, Gale B, Mossburg SE. In Conversati…
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - It provides a record, so that if you saw the patient last week and they came back in because they weren … Jones in the last week and maybe there’s an outbreak of something.
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - SPOTLIGHT CASE
A Laceration that Needed a Proper Exam, Not an X-Ray
Citation Text:
Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
March 27, 2024 - SPOTLIGHT CASE
Hidden Heparins: HIT Happens
Citation Text:
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - Lack of Sepsis Recognition Leads to Delay in Care
Following Cesarean Delivery.
November 25, 2020
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean
Delivery. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesare…
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong
Medication
September 30, 2020
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
The Case
A 65-year-old woman co…
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psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - Critical Echocardiogram Result Lost to Follow-up
June 14, 2023
Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
The Case
A 63-year-old man with history of stroke, systolic heart failure, and ventric…
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psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
March 27, 2024 - SPOTLIGHT CASE
"Do You Want Everything Done?": Clarifying Code Status
Citation Text:
Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
…
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an
Order is Not Enough
April 28, 2021
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
Disclosure of Relev…
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psnet.ahrq.gov/node/60542/psn-pdf
May 27, 2020 - Life-Threatening Infant Overdose of Sodium Chloride
May 27, 2020
Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
The Case
An infant with trisomy 21 underwent repair of a…
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psnet.ahrq.gov/node/836879/psn-pdf
April 27, 2022 - In Conversation With... Michael L. Millenson
April 27, 2022
In Conversation With.. Michael L. Millenson. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-michael-l-millenson
December 16, 2021
Editor’s note: Michael L. Millenson is the President of Health Quality Advisors LLC, author of the c…
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…