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psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
June 02, 2021 - November 16, 2022
WebM&M Cases
The Consequences
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - appreciate the importance of physiologic insulin replacement in patients with type 1 diabetes, and the consequences
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psnet.ahrq.gov/node/865309/psn-pdf
May 29, 2024 - how, unfortunately, tracheostomy management is often
overlooked, and such errors can lead to grave consequences
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Failure to
do so can lead to tracheal and surrounding structure damage with severe clinical consequences
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psnet.ahrq.gov/node/49553/psn-pdf
January 01, 2008 - The true
consequences of false-positive results. JAMA. 1991;265:365-369. [go to PubMed]
4.
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psnet.ahrq.gov/web-mm/translating-normal-abnormal
October 02, 2019 - case above illustrates, poor translations can lead to miscommunication, which can result in adverse consequences
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psnet.ahrq.gov/node/49843/psn-pdf
October 01, 2018 - the greatest promise in improving outcomes for patients with sepsis while
minimizing the unintended consequences
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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - confirmation of NGT placement, apparently due
to miscommunication at change-of-shift, led to more serious consequences
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psnet.ahrq.gov/perspective/emergence-application-based-healthcare
August 05, 2022 - Safety concerns with consumer-facing mobile health applications and their consequences: a scoping review … You touched on this topic a little bit earlier, but what do you think could be some of the consequences
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psnet.ahrq.gov/perspective/conversation-francoise-marvel-md
August 05, 2022 - You touched on this topic a little bit earlier, but what do you think could be some of the consequences … Safety concerns with consumer-facing mobile health applications and their consequences: a scoping review
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
February 26, 2025 - In Conversation with...Albert Wu, MD, MPH
July 1, 2008
Citation Text:
In Conversation with..Albert Wu, MD, MPH. PSNet [internet]. 2008.In Conversation with...Albert Wu, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…
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psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - Wrong Catheter in the Right Patient
Citation Text:
Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Format:
Google Scholar BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/node/60269/psn-pdf
April 29, 2020 - Delayed Management of Necrotizing Soft Tissue Infection
– Who does the Patient Belong To?
April 29, 2020
Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the
Patient Belong To? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tiss…
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/node/866205/psn-pdf
July 10, 2024 - Hemorrhagic Shock after Elective Spine Surgery: Failure
to Rescue after Limited Response to Nursing Concerns.
July 10, 2024
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response
to Nursing Concerns. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hemorrhagic-sh…
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psnet.ahrq.gov/web-mm/silent-pain-neck
August 19, 2020 - Silent Pain in the Neck
Citation Text:
Bittner EA. Silent Pain in the Neck. 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/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose
Citation Text:
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - SPOTLIGHT CASE
Missed Appendicitis
Citation Text:
Adams JG. Missed Appendicitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/854897/psn-pdf
October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical
Record Causing an Accidental Medication Overdose
October 31, 2023
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an
Accidental Medication Overdose. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/weight-and-…
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psnet.ahrq.gov/node/49819/psn-pdf
February 01, 2018 - Signout Fallout
February 1, 2018
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/signout-fallout
Case Objectives
Understand the role of communication failures in medical errors and preventable adverse events.
Review the evidence in support of handoff improvement pr…