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psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
March 31, 2021 - – sometimes referred to as patient ‘ownership’ – is made clear in the American College of Surgeons’ code
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psnet.ahrq.gov/node/49765/psn-pdf
August 21, 2016 - failed to verify the absence of a pneumothorax or other chest radiograph problem
immediately after the code
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - A “code blue” was called and the child was successfully resuscitated after about 20 minutes, following
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psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
September 27, 2023 - is not feasible or possible for a provider to electronically place an order – for example, during a code
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psnet.ahrq.gov/web-mm/transfusion-overload
September 23, 2020 - She rapidly worsened and had a respiratory arrest; a code blue was called.
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psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
January 01, 2018 - told it's not that hard to highlight text that has been copied and pasted, either italicize or color code
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psnet.ahrq.gov/web-mm/nstemi-curbside-consultation
August 04, 2021 - Panic Attacks
June 30, 2021
WebM&M Cases
Code
-
psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - Decision Gone Bad
April 1, 2008
WebM&M Cases
Code
-
psnet.ahrq.gov/node/49831/psn-pdf
June 01, 2018 - She called a code blue, and resuscitation was initiated.
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
September 27, 2023 - Liposuction Gone Awry
March 1, 2006
WebM&M Cases
Code
-
psnet.ahrq.gov/web-mm/challenging-case-multiple-suicide-attempts-complex-patient-psychiatric-comorbidities
September 27, 2023 - Liposuction Gone Awry
March 1, 2006
WebM&M Cases
Code
-
psnet.ahrq.gov/web-mm/see-patient-first
September 27, 2023 - appropriate was 90% or greater for each of the following: 1) at the request of a nurse, 2) activation of a code
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psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
May 01, 2018 - Opportunity
January 1, 2004
WebM&M Cases
Code
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psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
January 07, 2015 - Dropping the Ball Despite an Integrated EMR
Citation Text:
Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/hiding-plain-sight
April 24, 2019 - Hiding in Plain Sight
Citation Text:
Weinberg JM. Hiding in Plain Sight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
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psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
March 01, 2004 - Video to Improve Patient Safety: Clinical and Educational Uses
Yan Xiao, PhD; Colin F. Mackenzie, MB, ChB; and F. Jacob Seagull, PhD | May 1, 2015
View more articles from the same authors.
Citation Text:
Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient S…
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psnet.ahrq.gov/node/49398/psn-pdf
May 01, 2003 - Bloody BP Cuff
May 1, 2003
Madan AK. Bloody BP Cuff. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/bloody-bp-cuff
The Case
Patient #1, a 28-year-old male, was a trauma patient following a motor vehicle collision into a cement pillar.
Patient #1 was in the trauma bay with massive injuries and profuse bleed…
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psnet.ahrq.gov/node/33733/psn-pdf
July 01, 2012 - Patient Safety and Health Information Technology:
Learning from Our Mistakes
July 1, 2012
Koppel R. Patient Safety and Health Information Technology: Learning from Our Mistakes. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
Perspe…
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psnet.ahrq.gov/node/49665/psn-pdf
September 01, 2012 - Undetected Foreign Object
September 1, 2012
Cima RR. Undetected Foreign Object. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/undetected-foreign-object
The Case
A 75-year-old man with a past medical history of end-stage renal disease (on hemodialysis), hypertension,
and diabetes was found to have obstruct…
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psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
September 01, 2014 - A Costly Colonoscopy Leads to a Delay in Diagnosis
Citation Text:
Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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