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psnet.ahrq.gov/web-mm/too-hot-comfort
May 19, 2015 - A surface temperature of more than 156°F by wet heat produces immediate tissue death as well as vessel
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psnet.ahrq.gov/web-mm/easily-forgotten-tube
June 01, 2016 - September 27, 2023
Frequency and type of situational awareness errors contributing to death
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psnet.ahrq.gov/node/49713/psn-pdf
June 01, 2014 - CVC-associated air embolism is a preventable complication that can result in serious harm, including
death
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psnet.ahrq.gov/node/49837/psn-pdf
August 01, 2018 - The goal of treatment of asymptomatic AAA is to prevent future rupture and its associated risk of death
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psnet.ahrq.gov/node/73999/psn-pdf
October 27, 2021 - Medication errors are not always reversible and can cause permanent damage or
death; therefore, our
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - This particular case was reviewed within an hour of the patient's death.
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psnet.ahrq.gov/node/49569/psn-pdf
September 01, 2008 - nonenteral system, such as an intravascular
line or peritoneal dialysis catheter, can result in sepsis and death
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psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation
February 01, 2003 - cause analyses, and any other professional exchange of information related to a patient's injury or death
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psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
May 01, 2012 - bundle checklist combined with physician confirmation reduces risk of nosocomial complications and death
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psnet.ahrq.gov/web-mm/bowel-prep
March 01, 2017 - Colon cancer is the third leading cause of cancer death for women in the United States ( 1 ).
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psnet.ahrq.gov/web-mm/lethal-vertigo
September 20, 2011 - A subsequent review of the case indicated that the death was potentially avoidable, had life-saving neurosurgery
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psnet.ahrq.gov/web-mm/lap-burn
March 01, 2018 - Lap Burn
Citation Text:
Ball K. Lap Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/node/49441/psn-pdf
March 01, 2004 - Fumbled Handoff
March 1, 2004
Vidyarthi A. Fumbled Handoff. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/fumbled-handoff
The Case
A 73-year-old female with history of hypertension, non-insulin dependent diabetes mellitus (NIDDM), and
chronic renal insufficiency was admitted for an elective sigmoid resect…
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psnet.ahrq.gov/node/33815/psn-pdf
September 01, 2016 - Telemedicine and Patient Safety
September 1, 2016
Agboola SO, Kvedar JC. Telemedicine and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/telemedicine-and-patient-safety
Perspective
A paradigm shift is ongoing in the health care sector. The traditional model of episodic and hospital-base…
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psnet.ahrq.gov/node/49390/psn-pdf
February 01, 2003 - Flying Object Hits MRI
February 1, 2003
Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/flying-object-hits-mri
The Case
A child was brought to the Magnetic Resonance Imaging (MRI) room for a brain scan. Accompanied by an
anesthesiologist, the child was receiving…
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psnet.ahrq.gov/node/49839/psn-pdf
August 01, 2018 - Mixup Beyond the Medication Label
August 1, 2018
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
The Case
An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another
hospi…
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psnet.ahrq.gov/node/49387/psn-pdf
February 01, 2003 - Patient Mix-Up
February 1, 2003
Shojania KG. Patient Mix-Up. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/patient-mix
The Case
Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general
medical service at an academic medical center. Overnight, another man wit…
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - National Patient Safety Goals
Citation Text:
Shaikh U. National Patient Safety Goals. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
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psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
July 02, 2011 - enclosed within the rigid skull, large-volume hemorrhages produce more severe symptoms including coma and death
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psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
November 16, 2022 - Although the nurse's error in setting up the CRRT machine was not the direct cause of the patient's death