-
psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
June 01, 2016 - Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis
-
psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
January 07, 2015 - Although the case refers to the incident as an error, it is not clear that the events in the case meet
-
psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - where the fall occurred called a multidisciplinary "fall huddle" to reenact the circumstances of the incident
-
psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
March 25, 2020 - The Commentary
By Christian Bohringer MD
This incident describes a common type of adverse drug
-
psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - References
Figures
Related Resources From the Same Author(s)
Learning from incident
-
psnet.ahrq.gov/web-mm/caution-interrupted
October 01, 2016 - Interruptions
Although this specific incident involves the interruption and distraction of a nurse,
-
psnet.ahrq.gov/web-mm/mitigating-risk-intrahospital-transport-pediatric-patients-risk-physiologic-instability
May 27, 2020 - The patient remained intubated, and was transported back to the PICU without incident, although still
-
psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
January 07, 2015 - The remainder of the CABG was completed without incident, and the patient was weaned off cardiopulmonary
-
psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
July 30, 2020 - Coronavirus Disease 2019 (COVID-19) and Diagnostic Error
Citation Text:
Desai AN, Romano PS. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
Copy Citation
Format:
…
-
psnet.ahrq.gov/node/73336/psn-pdf
May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping
Healthcare Providers
May 26, 2021
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
The Case
…
-
psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis.
February 1, 2023
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
The Cases
Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
-
psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx
Spotlight
Respiratory Distress after Neck Surgery: Two
Cases of Post-Operative Cervical Hematoma
Source and Credits
• This presentation is based on the January 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…
-
psnet.ahrq.gov/node/49675/psn-pdf
February 01, 2013 - Delay in Treatment: Failure to Contact Patient Leads to
Significant Complications
February 1, 2013
Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet
[internet]. 2013.
https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complicat…
-
psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
September 01, 2017 - Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks
Citation Text:
Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
…
-
psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
March 01, 2007 - The Role of the Patient in Improving Patient Safety
Rosemary Gibson, MSc | March 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. Rockville…
-
psnet.ahrq.gov/web-mm/transfusion-overload
September 23, 2020 - SPOTLIGHT CASE
Transfusion Overload
Citation Text:
Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML En…
-
psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - SPOTLIGHT CASE
False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.
Citation Text:
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
December 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case December 2004
Discharge Fumbles
Source and Credits
This presentation is based on the Dec. 2004
AHRQ WebM&M Spotlight Case in Hospital Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Alan Forster, M…
-
psnet.ahrq.gov/node/49860/psn-pdf
April 01, 2019 - Hip Fractures in Older Patients: the Case for Geriatrics
Comanagement
April 1, 2019
Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
The Case
An 82-year-old man …
-
psnet.ahrq.gov/web-mm/mark-my-tooth
June 01, 2014 - Mark My Tooth
Citation Text:
Smith RA. Mark My Tooth. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
D…