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psnet.ahrq.gov/node/33785/psn-pdf
May 01, 2015 - researchers, the idea that it's not about the physician, it's about the entire team
and about the entire episode
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psnet.ahrq.gov/node/49525/psn-pdf
December 01, 2006 - experience no recurrence of
thrombocytopenia upon re-challenge with heparin as soon as 1.5 months after an episode
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psnet.ahrq.gov/perspective/quality-and-safety-challenges-critical-care-preventing-and-treating-delirium-intensive
December 01, 2012 - this kind of focus, studies have shown a more than doubling of risk of incident dementia following an episode
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psnet.ahrq.gov/web-mm/deadly-duo
April 28, 2021 - The patient survived the episode without any life-threatening arrhythmias and was transferred to an inpatient
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - knowledge deficit may be a
greater factor in misdiagnosis than cognitive biases in cases such as this episode
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - The nurse, reluctant to administer this medication in light of the recent episode of somnolence, attempted
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psnet.ahrq.gov/node/840256/psn-pdf
November 16, 2022 - It’s not an episode of care; it’s part of that older adult patient’s journey where
they might be experiencing
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - The patient remained hemodynamically stable throughout the episode, culminating in adequate reversal
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psnet.ahrq.gov/issue/incidence-adverse-drug-reactions-hospitalized-patients-meta-analysis-prospective-studies
October 04, 2017 - Study
Classic
Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies.
Citation Text:
Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective st…
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psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - Are You Mrs. A? An Issue of Identification Over Telephone
Citation Text:
Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
…
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psnet.ahrq.gov/web-mm/real-heartache
October 01, 2018 - A Real Heartache
Citation Text:
Polevoi SK. A Real Heartache. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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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/web-mm/departure-central-line-ritual
October 13, 2018 - Departure From Central Line Ritual
Citation Text:
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndN…
-
psnet.ahrq.gov/node/49461/psn-pdf
September 01, 2004 - Reaction to Dye
September 1, 2004
Cohan R. Reaction to Dye. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/reaction-dye
The Case
A patient was referred to urology after having several episodes of gross hematuria. The urologist thought
that the patient might have a renal mass and sent him to radiology for a…
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psnet.ahrq.gov/periodic-issue/periodic-issue-324
January 07, 2022 - January 12, 2022 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/periodic-issue/periodic-issue-391
April 26, 2023 - May 17, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, a…
-
psnet.ahrq.gov/web-mm/central-line-clot
August 04, 2021 - SPOTLIGHT CASE
Central Line Clot
Citation Text:
Randolph AG. Central Line Clot. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
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psnet.ahrq.gov/node/74251/psn-pdf
January 26, 2022 - Delayed Diagnosis and Treatment of an Occult
Hemothorax Following Complicated Central Line Insertion
Leads to Cardiac Arrest
January 26, 2022
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated
Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022.
https…
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psnet.ahrq.gov/node/846769/psn-pdf
March 29, 2023 - Missed Diagnosis of Addison’s Disease in Adolescent
Presenting with Fatigue.
March 29, 2023
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
The C…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
January 01, 2019 - Spotlight
Spotlight
Mistaken Attribution, Diagnostic Misstep
*
Source and Credits
This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD
…
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psnet.ahrq.gov/node/73456/psn-pdf
June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult
Intubation and Severe Hypoxemia
June 30, 2021
Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…