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psnet.ahrq.gov/issue/doctor-administered-fatal-dose-calcium-baby-inquest-told
March 06, 2005 - Newspaper/Magazine Article
Doctor administered fatal dose of calcium to baby, inquest told.
Citation Text:
Doctor administered fatal dose of calcium to baby, inquest told. Morris S.
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psnet.ahrq.gov/issue/nqf-safe-practices-2010-updates
July 14, 2010 - Special or Theme Issue
NQF Safe Practices: 2010 Updates.
Citation Text:
NQF Safe Practices: 2010 Updates. J Patient Saf. 2010;6(1):1-47, 52-56.
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psnet.ahrq.gov/issue/think-you-cant-make-medication-errors
March 01, 2023 - Newspaper/Magazine Article
Think you can't make medication errors?
Citation Text:
Think you can't make medication errors? Kromis L. Outpatient Surgery Magazine. March 2013.
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psnet.ahrq.gov/node/836811/psn-pdf
April 07, 2022 - Implementing a watcher program to improve timeliness of
recognition of deterioration in hospitalized children
April 7, 2022
Evans S, Green A, Roberson A, et al. Implementing a watcher program to improve timeliness of
recognition of deterioration in hospitalized children. J Pediatr Nurs. 2021;61:151-6.
https:/…
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psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - patient’s nurse identified the misconnection, returned the vancomycin drip to the peripheral IV line, assessed
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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - Finally, needle position can be assessed by attaching insufflation tubing to the Veress needle and measuring
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psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
February 05, 2020 - mounted on the anesthesia machine and the gas hoses in the anesthetizing location should be visually assessed
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psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - They assessed the types of behaviors that frontline caregivers perceived as intimidating: impatience
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psnet.ahrq.gov/node/33873/psn-pdf
February 01, 2019 - SS: Right now there is a disconnect between how students are assessed for residency programs and the
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psnet.ahrq.gov/perspective/conversation-jeffrey-starke-md
September 11, 2023 - It allows people to go in and be professionally assessed in a fairly convenient way.
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psnet.ahrq.gov/web-mm/inadvertent-castration
October 27, 2010 - Inadvertent Castration
Citation Text:
Calland FJ. Inadvertent Castration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/bowel-prep
March 01, 2017 - Bowel Prep
Citation Text:
Nelson D. Bowel Prep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/walking-patient-missing-drain
April 01, 2006 - Walking Patient, Missing Drain
Citation Text:
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
November 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Diagnostic Errors Case Studies
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Created By: Maria Mirica, PRIDE Group
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.317_slideshow.ppt
March 01, 2014 - PowerPoint Presentation
Spotlight Case
Tough Call: Addressing Errors From Previous Providers
1
This presentation is based on the March 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: William Martinez, MD, MS, Assistant Professor of Medicine, …
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psnet.ahrq.gov/node/49610/psn-pdf
October 01, 2010 - "Recurrent" Appendicitis
October 1, 2010
Greenberg CC. "Recurrent" Appendicitis. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/recurrent-appendicitis
The Case
An 85-year-old man presented to the emergency department (ED) with right lower quadrant pain. On
physical examination, the patient showed rebound t…
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psnet.ahrq.gov/node/49607/psn-pdf
August 01, 2010 - Missed Patient Assignment: Is Anyone There?
August 1, 2010
Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
The Case
In one hospital, nurses' patient assignments were communicated by listing the…
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psnet.ahrq.gov/node/50927/psn-pdf
February 21, 2020 - Patient Safety in Primary Care
February 21, 2020
Schiff G, Hall KK, Fitall E. Patient Safety in Primary Care. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/patient-safety-primary-care
Introduction
A strong primary care system is foundational to achieving high-quality, accessible, efficient healthcare …
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psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3
Citation Text:
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx
Spotlight
Premature Closure: Was it Just Syncope?
Source and Credits
• This presentation is based on the November 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit i…