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psnet.ahrq.gov/web-mm/blind-spot
July 30, 2020 - WebM&M Cases
To Dilute or Not Dilute: Drug Errors and Consequences
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psnet.ahrq.gov/node/837791/psn-pdf
August 05, 2022 - 10-year-analysis-based-medical-malpractice-claims
exposure, false-positive results , psychological consequences
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - This system has failed and will continue to fail—sometimes with disastrous consequences.
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psnet.ahrq.gov/node/49648/psn-pdf
March 01, 2012 - But, many hospitalizations owe to errors in diagnosis,
consequences of treatment (most commonly adverse
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psnet.ahrq.gov/web-mm/emergent-triage-miss
March 06, 2015 - The patient experienced no major long-term consequences.
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psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
March 01, 2011 - documents that handovers often lack important elements, and that poor quality handovers can cause adverse consequences … Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168:1755-1760.
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psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
August 01, 2014 - Patients are under constant observation, and it's very easy to realize that something has gone wrong—the consequences … US : I think you'd be more tied to the downstream consequences.
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psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
August 22, 2014 - Patients are under constant observation, and it's very easy to realize that something has gone wrong—the consequences … US : I think you'd be more tied to the downstream consequences.
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - supplements for a patient on furosemide is routine, however, this same
drug may lead to life-threatening consequences … Numerous barriers to reporting exist including fear of
consequences, a culture of blame, perception
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psnet.ahrq.gov/node/73104/psn-pdf
January 04, 2021 - , developers need to proactively develop comprehensive mitigation strategies to
address unintended consequences … invest in research and evaluation that will enable this purposeful learning risks
repeating the tragic consequences
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psnet.ahrq.gov/node/49403/psn-pdf
June 01, 2003 - Missed Appendicitis
June 1, 2003
Adams JG. Missed Appendicitis. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/missed-appendicitis
Case Objectives
Appreciate the variable presentations of appendicitis
List complications of missed appendicitis
Understand the advantages and disadvantages of CT in diagnosing…
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psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
December 21, 2017 - High-Risk Medications, High-Risk Transfers
Citation Text:
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibTeX EndNote …
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psnet.ahrq.gov/web-mm/premature-or-overdue
December 23, 2020 - Premature or Overdue?
Citation Text:
Thomas J, Hannah M. Premature or Overdue?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
March 26, 2015 - Right Place, Right Drug, Wrong Strength
Citation Text:
Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/node/33670/psn-pdf
July 01, 2008 - In Conversation with...Albert Wu, MD, MPH
July 1, 2008
In Conversation with..Albert Wu, MD, MPH. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
Editor's note: Albert Wu, MD, MPH, is Professor of Health Policy and Management at the Johns Hopkins
School of Public Health…
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psnet.ahrq.gov/node/49620/psn-pdf
February 01, 2011 - Silent Pain in the Neck
February 1, 2011
Bittner EA. Silent Pain in the Neck. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/silent-pain-neck
The Case
A 60-year-old man with no significant past medical history underwent an elective anterior cervical
discectomy for persistent right arm weakness due to cervi…
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psnet.ahrq.gov/node/60543/psn-pdf
May 27, 2020 - Wrong Catheter in the Right Patient
May 27, 2020
Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
The Case
A 55-year-old man with history of emphysema was admitted to the hospital for pneumonia. The patient had
two?peripheral…
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psnet.ahrq.gov/node/49426/psn-pdf
November 01, 2003 - Don't Push
November 1, 2003
Meltzer HY. Don't Push. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dont-push
The Case
A 37-year-old HIV-positive woman was brought to the emergency room by her family because she had
exhibited altered mentation for 3 days. The patient had been diagnosed with HIV infection 3 …
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psnet.ahrq.gov/node/49662/psn-pdf
August 01, 2012 - Wrong Turn through Colon: Misplaced PEG
August 1, 2012
Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
The Case
An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…
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psnet.ahrq.gov/node/33675/psn-pdf
October 01, 2008 - Identifying Adverse Events Not Present on Admission:
Can We Do It?
October 1, 2008
Naessens JM. Identifying Adverse Events Not Present on Admission: Can We Do It? PSNet [internet].
2008.
https://psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
Perspective
Interest is growi…