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  1. psnet.ahrq.gov/web-mm/unfamiliar-catheter
    November 01, 2006 - The Unfamiliar Catheter Citation Text: Swayze SC, James A. The Unfamiliar Catheter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
  2. psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
    January 01, 2019 - Spotlight Missed Opportunities for Suicide Risk Assessment Source and Credits • This presentation is based on the November 2019 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Glen Xiong, MD & Debra Kahn, MD ○ Editors in Chief, AHRQ We…
  3. psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
    January 29, 2020 - Delayed Recognition of a Positive Blood Culture Citation Text: Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibT…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49531/psn-pdf
    March 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses…
  5. psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
    November 15, 2023 - Complications of Vascular Access Procedures in Patients with Kidney Disease Citation Text: Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
  6. psnet.ahrq.gov/web-mm/transfer-or-not-transfer
    November 23, 2016 - SPOTLIGHT CASE To Transfer or Not to Transfer Citation Text: Pines JM. To Transfer or Not to Transfer. 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 …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49455/psn-pdf
    July 01, 2004 - The Worst Headache July 1, 2004 Edlow JA. The Worst Headache. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/worst-headache The Case A 48-year-old woman with a history of migraine headaches and hypertension presented to her outpatient clinic with a 4-day history of headache. While shopping 4 days earlier, …
  8. psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx Spotlight Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the ful…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49408/psn-pdf
    July 01, 2003 - Check the Wristband July 1, 2003 Rosenthal M. Check the Wristband. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/check-wristband The Case The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the impending surgery. The patient spoke English and appeared to be of aver…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33663/psn-pdf
    September 15, 2008 - Implementing a Patient Safety Program at a Large National Health System January 1, 2008 Hauck LD, Jacob J. Implementing a Patient Safety Program at a Large National Health System. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system Perspectiv…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49482/psn-pdf
    May 01, 2005 - Pregnant With Danger May 1, 2005 Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/pregnant-danger The Case A 35-year-old woman, 38 weeks pregnant, presented to the emergency department (ED) in the middle of the night complaining of left leg pain. She also had so…
  12. psnet.ahrq.gov/web-mm/forgotten-line
    March 11, 2011 - The Forgotten Line Citation Text: Render ML. The Forgotten Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49799/psn-pdf
    July 01, 2017 - Delayed Recognition of a Positive Blood Culture July 1, 2017 Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture The Case A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…
  14. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
    September 01, 2014 - PowerPoint Presentation Spotlight A Lot of Pain (Medications) 1 This presentation is based on the September 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Shoshana J. Herzig, MD, MPH, Division of General Medicine, Beth Israel Deaconess Medic…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33674/psn-pdf
    February 01, 2009 - In Conversation with…Robert M. Wachter, MD October 1, 2008 In Conversation with…Robert M. Wachter, MD. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md Editor's note: At the University of California, San Francisco, Robert M. Wachter, MD, is Professor and Chief of the…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867985/psn-pdf
    January 01, 2025 - Suicide Prevention March 25, 2025 Boudreaux E, Gale B, Mossburg SE. Suicide Prevention. PSNet [internet]. 20024. https://psnet.ahrq.gov/perspective/suicide-prevention Introduction Suicide is one of the leading causes of death in the United States, accounting for nearly 50,000 deaths in 2022, a 36% rise since 2000…
  17. psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
    January 03, 2017 - SPOTLIGHT CASE Treatment Challenges After Discharge Citation Text: Coffey C. Treatment Challenges After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar Bib…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49437/psn-pdf
    March 01, 2004 - Crossing the Line March 1, 2004 Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/crossing-line Case Objectives Review complications of central venous catheterization Discuss patient and operator factors that affect complication rates Describe methods for preventing c…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49698/psn-pdf
    December 01, 2013 - SNFs: Opening the Black Box December 1, 2013 Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/snfs-opening-black-box The Case An 88-year-old woman was admitted to a skilled nursing facility (SNF) after a lengthy hospitalization for a small bowel obstructio…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49660/psn-pdf
    August 01, 2012 - No News May Not Be Good News August 1, 2012 Moore CR. No News May Not Be Good News. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news Case Objectives Describe the frequency with which ambulatory test results are not followed up by providers. Appreciate that inadequate follow-up of…

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