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psnet.ahrq.gov/web-mm/thin-air
March 01, 2006 - in providing supplemental oxygen, the patient's underlying disease was likely severe enough to cause death
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - //psnet.ahrq.gov/issue/doctors-orders-killed-cancer-patient-dana-farber-admits-drug-overdose-caused-death-globe
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psnet.ahrq.gov/node/33702/psn-pdf
November 01, 2010 - We actually changed the name of the AHRQ measure
so it's now called Death Among Surgical Patients with
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psnet.ahrq.gov/node/33807/psn-pdf
May 01, 2016 - having heard these alarms were an indication of alarm fatigue and that it
contributed to the patient's death
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - was performed, which confirmed that although the patient did have tumor lysis syndrome, the cause of death
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psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
May 11, 2014 - Vial Mistakes Involving Heparin
Citation Text:
Vanderveen T. Vial Mistakes Involving Heparin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - A Mid-Summer Fog
Citation Text:
Braddock CH. A Mid-Summer Fog. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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…
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psnet.ahrq.gov/web-mm/finding-fault-default-alert
August 28, 2024 - Finding Fault With the Default Alert
Citation Text:
Baysari M. Finding Fault With the Default Alert. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/forgotten-med
July 01, 2006 - The Forgotten Med
Citation Text:
Cucina R. The Forgotten Med. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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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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psnet.ahrq.gov/node/49583/psn-pdf
April 01, 2009 - Eptifibatide Epilogue
April 1, 2009
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/eptifibatide-epilogue
The Case
A 62-year-old man was admitted at 11:00 PM on a Saturday night with the provisional diagnosis of acute
coronary syndrome. Serial testing for mark…
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psnet.ahrq.gov/node/33711/psn-pdf
May 01, 2011 - The Second Victim Phenomenon: A Harsh Reality of
Health Care Professions
May 1, 2011
Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [internet].
2011.
https://psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
Perspective
The Instit…
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psnet.ahrq.gov/node/33712/psn-pdf
June 01, 2011 - In Conversation with… Edward Tenner, PhD
June 1, 2011
In Conversation with… Edward Tenner, PhD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
Editor's note: Edward Tenner is an independent writer, speaker, and consultant on technology and
culture. He received his PhD fro…
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psnet.ahrq.gov/node/49706/psn-pdf
January 01, 2015 - Clostridium Difficile Relapse Secondary to Medication
Access Issue
April 1, 2014
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
The Case
A 24-year-old wom…
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psnet.ahrq.gov/node/49504/psn-pdf
March 01, 2006 - Liposuction Gone Awry
March 1, 2006
Yates JA. Liposuction Gone Awry. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/liposuction-gone-awry
The Case
A 54-year-old man with HIV was referred to a plastic surgeon for cosmetic surgery. In the plastic surgeon’s
office, he underwent neck and facial liposuction wit…
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psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
March 29, 2023 - Walking Out of a Hospital After Attempted Suicide
Citation Text:
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
January 29, 2021 - Even though this problem occurs rarely, brain damage and death attributed to difficult airway management
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psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
September 15, 2024 - WebM&M Cases
Medication Mix-Up Leads to Patient Death
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psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - However, it has been estimated that for each preventable death, there are between 7–100 close calls that
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psnet.ahrq.gov/web-mm/compare-and-contrast
July 16, 2019 - without CN; adjustment for differences in co-morbidities yielded a 5.5-fold increase in the odds of death