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psnet.ahrq.gov/web-mm/carpe-diem-seize-day
September 01, 2012 - Carpe Diem (Seize the Day)
Citation Text:
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/49434/psn-pdf
February 01, 2004 - Undiagnosed Vaginal Bleeding
February 1, 2004
Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
The Case
The patient is a 34-year-old gravida 3, para 3 woman with a 2-year history of increasingly profuse vaginal
bleeding. Over the past…
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psnet.ahrq.gov/node/846125/psn-pdf
March 15, 2023 - The I-READI Quality and Safety Framework: Strong
Communications Channels and Effective Practices to
Rapidly Update and Implement Clinical Protocols During a
Time of Crisis
March 15, 2023
https://psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-
and-effective
Summary
…
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psnet.ahrq.gov/node/72693/psn-pdf
January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room
– Mixing Up the Ampules
January 29, 2021
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
The Case
A…
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psnet.ahrq.gov/node/49823/psn-pdf
March 01, 2018 - Shortcuts to Acetaminophen-induced Liver Failure
March 1, 2018
Bacak S, Thornburg L. Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure
The Case
An 18-year-old woman, 27 weeks pregnant, presented to the emergency dep…
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psnet.ahrq.gov/node/33632/psn-pdf
April 01, 2006 - In Conversation with… Michael Cohen, RPh, MS, ScD
(hon)
April 1, 2006
In Conversation with… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background and how…
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psnet.ahrq.gov/node/860049/psn-pdf
January 04, 2024 - Myasthenia Crisis after a Delayed Diagnosis in a
Medically Complex Patient.
January 4, 2024
Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. PSNet [internet].
2024.
https://psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
The Case
A 9…
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psnet.ahrq.gov/node/33682/psn-pdf
April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH
April 1, 2009
In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
Editor's note: Mark R. Chassin, MD, MPP, MPH, is president of The Joint Commission, the preeminent
s…
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psnet.ahrq.gov/node/49797/psn-pdf
June 01, 2017 - Diagnostic Overshadowing Dangers
June 1, 2017
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
The Case
A 72-year-old woman with history of opioid abuse was sent to the emergency department (ED) from a
methadone clinic because she a…
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psnet.ahrq.gov/node/33772/psn-pdf
September 01, 2014 - In Conversation With… Rosemary Gibson, MSc
September 1, 2014
In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
Editor's note: Rosemary Gibson, MSc, is Senior Advisor to The Hastings Center and an editor for JAMA
Internal Medicin…
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psnet.ahrq.gov/node/33639/psn-pdf
September 01, 2006 - In Conversation with...James P. Bagian, MD
September 1, 2006
In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: Where did your interest in safety come from?
Dr. James Bagian: I don't know …
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psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-and-improve-health
February 26, 2025 - Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes
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March 29, 2023
Innovation
Co…
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
July 21, 2025 - Breadcrumb
Home
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Diagnostic Errors Case Studies
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Created By: Maria Mirica, PRIDE Group
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psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
September 24, 2024 - dashboards to track harms and sought to define themselves as a learning health system by deploying an education … Perspectives on Safety
The Role of Undergraduate Nursing Education
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psnet.ahrq.gov/perspective/conversation-charles-vincent-mphil-phd
July 10, 2024 - There is more on patient safety in education and training, and I think the research has taken off, and
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psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
February 26, 2025 - From an education theory, they often come in at that level of unconscious incompetence, and we get them
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psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
April 12, 2023 - relationship with the manufacturers of any commercial products discussed in this continuing medical education
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - The attending must balance the education of proceduralist trainees with risk to the patient.
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psnet.ahrq.gov/node/865610/psn-pdf
April 24, 2024 - Education Development Center. Zero Suicide. Accessed February 12, 2024.
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psnet.ahrq.gov/web-mm/lung-nodule-refused-grow
March 01, 2004 - relationship with the manufacturers of any commercial products discussed in this continuing medical education