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psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
March 27, 2024 - untreated, the patient will eventually develop focal neurological deficits, often with devastating consequences
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - Consequences and complications of peritoneal adhesions. Colorectal Dis. 2007;9 Suppl 2:25-34.
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psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
March 24, 2021 - opportunity to focus on necrotizing fasciitis as this diagnosis is often missed or delayed with devastating consequences
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psnet.ahrq.gov/node/867359/psn-pdf
December 18, 2024 - an ideal response
of counseling breastfeeding mothers who requested infant formula about possible consequences
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psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
January 29, 2021 - obesity is increasing worldwide; anesthesia care providers must understand the adverse cardiopulmonary consequences
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psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
August 14, 2024 - Predictors and consequences of hematoma after thyroidectomy: an American College of Surgeons National
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psnet.ahrq.gov/web-mm/pill-organizing-plight
June 19, 2018 - Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13:57-65.
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - pre-incision checklist likely contributed to this near miss, which may happen again in the future (with worse consequences
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psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
May 28, 2020 - implantable, life-saving devices. [1] Ineffective or unsafe medical devices can have detrimental consequences
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - June 30, 2021
WebM&M Cases
Consequences of Medical Overuse
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - Fortunately, the boy did not experience any adverse consequences from the hypernatremia.
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psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
March 27, 2024 - We spoke with him about the HITECH Act and the consequences—anticipated and otherwise—of the digitization
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psnet.ahrq.gov/node/49579/psn-pdf
March 21, 2009 - All in the History
March 21, 2009
Fee C. All in the History. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/all-history
Case Objectives
Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it
does not apply to transfers to emergency departments from non-acute care faci…
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psnet.ahrq.gov/node/73642/psn-pdf
August 25, 2021 - Sudden Collapse During Upper Gastrointestinal
Endoscopy: Expect the Unexpected
August 25, 2021
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-
unexpected
…
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psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound
and Patient Safety
July 1, 2018
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
Case Objectives
Unders…
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psnet.ahrq.gov/node/33734/psn-pdf
August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD
August 1, 2012
In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
Editor's note: The topic of patient safety in long-term care facilities has not received the attent…
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - SPOTLIGHT CASE
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.
Citation Text:
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSNet [internet]. Rockville (MD):…
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psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
March 31, 2021 - Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?
Citation Text:
Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
August 31, 2025 - Breadcrumb
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet T…
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psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors
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March 3, 2021
Innovation…