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  1. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 …
  2. 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. …
  3. 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. Copy Citation Format: Google Schol…
  4. 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. Copy Citation Format: Google Scholar BibTeX En…
  5. 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. Copy Citatio…
  6. 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. Copy Citation Format: Google…
  7. 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…
  8. 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 (…
  9. 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…
  10. 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.
  11. 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. Copy Cit…
  12. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

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

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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