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psnet.ahrq.gov/node/49663/psn-pdf
September 01, 2012 - Peripheral IV in Too Long
September 1, 2012
Fang C-T. Peripheral IV in Too Long. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/peripheral-iv-too-long
Case Objectives
Appreciate the complications associated with peripheral intravenous (IV) catheters.
Describe the optimal sterile technique that should be us…
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psnet.ahrq.gov/node/49602/psn-pdf
April 01, 2010 - Anticoagulation: Held Too Long
April 1, 2010
Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
The Case
A 68-year-old woman with a history of mitral valve replacement with a mechanical valve was admitted with
abdominal pain. Because of the…
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psnet.ahrq.gov/node/49864/psn-pdf
June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You
in Training About Feedback and Burnout
June 1, 2019
Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About
Feedback and Burnout. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…
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psnet.ahrq.gov/node/838855/psn-pdf
October 27, 2022 - False Assumptions Result in a Missed Pneumothorax
after Bronchoscopy with Transbronchial Biopsy.
October 27, 2022
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy
with Transbronchial Biopsy. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/false-assumptions-resul…
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psnet.ahrq.gov/node/49552/psn-pdf
January 01, 2008 - How Do Providers Recover From Errors?
January 1, 2008
West CP. How Do Providers Recover From Errors? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
Case Objectives
Describe the provider-specific prevalence of medical errors.
Appreciate the impact of medical errors on care pr…
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered
Nurses and Paramedics To Provide Home Visits to
Recently Discharged Patients at Highest Risk for Hospital
Readmission
April 7, 2022
https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-
paramedics-provide-home
Sum…
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psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
October 30, 2024 - A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic
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April 27, 2022
Innovation
Conta…
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psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - The Wrong Shot: Error Disclosure
June 1, 2004
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
Case Objectives
Describe the rationale for disclosing harmful errors to patients.
Describe the specific information that patie…
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psnet.ahrq.gov/node/33707/psn-pdf
February 01, 2011 - The University of Texas System Clinical Safety and
Effectiveness Course
February 1, 2011
Thomas EJ, Patterson JE, Martin S, et al. The University of Texas System Clinical Safety and
Effectiveness Course. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiv…
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psnet.ahrq.gov/node/49699/psn-pdf
February 01, 2014 - Multifactorial Medication Mishap
February 1, 2014
Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
Case Objectives
Understand the system-based causes of medication errors.
Describe a model for a systems approach to error analysis.
Id…
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psnet.ahrq.gov/node/33674/psn-pdf
February 01, 2009 - In Conversation with…Robert M. Wachter, MD
October 1, 2008
In Conversation with…Robert M. Wachter, MD. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
Editor's note: At the University of California, San Francisco, Robert M. Wachter, MD, is Professor and
Chief of the…
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psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
January 01, 2024 - The Different Count Contributions to Retention
Differential Count Contributions in Retained Surgical Sponge Cases: Examination of Administrative Penalty
Cases from the California Department of Public Health (CDPH), Health and Safety Code Section 1280.1
Enforcement Reports from 2007-2014
A NoThing Left Behin…
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psnet.ahrq.gov/node/33875/psn-pdf
March 01, 2019 - In Conversation With… Susan Haas, MD, MSc
March 1, 2019
In Conversation With… Susan Haas, MD, MSc. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
Editor's note: Dr. Haas is an obstetrician–gynecologist and co-Principal Investigator for Ariadne Labs'
work focused on health…
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - No News May Not Be Good News
August 1, 2012
Moore CR. No News May Not Be Good News. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
Case Objectives
Describe the frequency with which ambulatory test results are not followed up by providers.
Appreciate that inadequate follow-up of…
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psnet.ahrq.gov/node/49400/psn-pdf
May 01, 2003 - Central Line Clot
May 1, 2003
Randolph AG. Central Line Clot. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/central-line-clot
Case Objectives
List the complications of central line manipulation
Appreciate the limitations of diagnostic studies for PE in children
Describe modalities for prevention of cathe…
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psnet.ahrq.gov/node/33643/psn-pdf
December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA
December 1, 2006
In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
Editor's Note: J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and
Critic…
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)
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…
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psnet.ahrq.gov/curated-library/diagnostic-error
August 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Diagnostic Error
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Created By: Karen Cosby, AHRQ
Date Created: May 8, …
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - Personal Health Literacy
August 30, 2023
Bakerjian D. Personal Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/personal-health-literacy
Originally published in July 2017 by researchers at the University of California, San Francisco. Updated in
August 2023 by Deb Bakerjian, PhD, RN, APRN, FAA…
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psnet.ahrq.gov/node/843234/psn-pdf
January 01, 2013 - Overdose of Gabapentin and Oxycodone in a Patient with
End-Stage Renal Disease: A Case for Appropriate
Interruptive Drug-Disease Alerts.
February 1, 2023
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with
End-Stage Renal Disease: A Case for Appropriate Interruptive D…