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psnet.ahrq.gov/issue/national-quality-measures-clearinghouse-nqmc
October 23, 2019 - Database/Directory
National Quality Measures Clearinghouse (NQMC).
Citation Text:
National Quality Measures Clearinghouse (NQMC). Agency for Healthcare Research and Quality. 1998-2018.
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psnet.ahrq.gov/issue/more-families-hear-apologies-following-medical-mistakes
June 28, 2006 - Newspaper/Magazine Article
More families hear apologies following medical mistakes.
Citation Text:
More families hear apologies following medical mistakes. Greene L. St. Petersburg Times. August 19, 2008.
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psnet.ahrq.gov/issue/sterile-water-should-not-be-given-freely
March 18, 2010 - Newspaper/Magazine Article
Sterile water should not be given "freely."
Citation Text:
Sterile water should not be given "freely." PA-PSRS Patient Saf Advis. June 2008;5:53-56.
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psnet.ahrq.gov/issue/health-literacy
December 23, 2011 - Special or Theme Issue
Health Literacy.
Citation Text:
Health Literacy. J Gen Intern Med. 2006;21(8):806-899.
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psnet.ahrq.gov/issue/leadership-response-sentinel-event-respectful-effective-crisis-management
July 12, 2017 - Multi-use Website
Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management.
Citation Text:
Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management. Institute for Healthcare Improvement.
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psnet.ahrq.gov/issue/keeping-safety-priority-home-care-and-hospice-one-agencys-journey
June 05, 2019 - Commentary
Keeping safety a priority in home care and hospice: one agency's journey.
Citation Text:
Mullin LV. Keeping safety a priority in home care and hospice: one agency's journey. Home Healthc Nurse. 2010;28(2):63-70. doi:10.1097/NHH.0b013e3181cb5939.
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psnet.ahrq.gov/issue/diagnostic-errors-primary-care
May 03, 2023 - Multi-use Website
Diagnostic Errors in Primary Care.
Citation Text:
Diagnostic Errors in Primary Care. Betsy Lehman Center for Patient Safety.
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psnet.ahrq.gov/issue/plan-aims-cut-hospital-deaths
August 28, 2019 - Newspaper/Magazine Article
Plan aims to cut hospital deaths.
Citation Text:
Plan aims to cut hospital deaths. Appleby J.
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psnet.ahrq.gov/node/49604/psn-pdf
June 01, 2010 - Tacit Handover, Overt Mishap
June 1, 2010
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
The Case
A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3
years earlier to treat an abdo…
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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/49423/psn-pdf
November 01, 2003 - The Missing Suction Tip
November 1, 2003
Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/missing-suction-tip
Case Objectives
Identify the risk factors for retained foreign bodies.
Understand methods used to prevent and identify retained foreign bodies.
Apprecia…
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psnet.ahrq.gov/node/49722/psn-pdf
December 01, 2014 - Medical Devices in the "Wild"
December 1, 2014
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/medical-devices-wild
The Case
A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes,
chronic pain, arthritis, and…
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psnet.ahrq.gov/node/33682/psn-pdf
April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH
April 1, 2009
In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
Editor's note: Mark R. Chassin, MD, MPP, MPH, is president of The Joint Commission, the preeminent
s…
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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/49820/psn-pdf
February 01, 2018 - Returning Home Safely
February 1, 2018
Toles M. Returning Home Safely. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/returning-home-safely
The Case
A 72-year-old man was admitted to the hospital after a fall at home resulting in a right humerus fracture and
shoulder dislocation, as well as other injuries …
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psnet.ahrq.gov/node/49815/psn-pdf
December 01, 2017 - Over-the-Counter Oversight
December 1, 2017
Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/over-counter-oversight
The Case
A 56-year-old man was evaluated in the burn clinic for a second-degree burn on his chest. Although
portions of his skin we…
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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/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
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Diagnostic Errors Case Studies
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Created By: Maria Mirica, PRIDE Group
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psnet.ahrq.gov/web-mm/refused-medication-error
November 01, 2005 - Refused Medication Error
Citation Text:
Foley M. Refused Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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