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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/33696/psn-pdf
June 01, 2010 - In Conversation with…Pat Croskerry, MD, PhD
June 1, 2010
In Conversation with…Pat Croskerry, MD, PhD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
Editor's note: Pat Croskerry, MD, PhD, is a professor in emergency medicine at Dalhousie University in
Halifax, Nova…
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psnet.ahrq.gov/node/33774/psn-pdf
December 01, 2014 - In Conversation With… Edward Kelley, PhD
December 1, 2014
In Conversation With… Edward Kelley, PhD. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-edward-kelley-phd
Editor's note: Edward Kelley, PhD, is Director of Service Delivery and Safety for the World Health
Organization (WHO). He ha…
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psnet.ahrq.gov/node/49540/psn-pdf
August 21, 2007 - Resuscitation Errors: A Shocking Problem
August 21, 2007
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
Case Objectives
Appreciate that delays in defibrillation can have significant negative effects on sur…
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psnet.ahrq.gov/node/60172/psn-pdf
March 01, 2021 - Verification Screen That Includes Prominent Patient
Photograph Significantly Reduces Errors Caused by
Orders Placed in Wrong Chart
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-
reduc…
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - In Conversation with…David W. Bates, MD, MSc
May 1, 2008
In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
Editor's note: Dr. David Bates is a Professor at Harvard Medical School, Medical Director of Clinical and
Quality …
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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - Tough Call: Addressing Errors From Previous Providers
March 1, 2014
Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
Case Objectives
Define what it means to be a professional.
Identi…
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psnet.ahrq.gov/node/33849/psn-pdf
January 01, 2018 - In Conversation With… Robert Hirschtick, MD
January 1, 2018
In Conversation With… Robert Hirschtick, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
Editor's note: Dr. Hirschtick is Associate Professor of Medicine at Northwestern Medicine, and the author
of a numbe…
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psnet.ahrq.gov/node/33746/psn-pdf
March 01, 2013 - In Conversation With… David M. Gaba, MD
March 1, 2013
In Conversation With… David M. Gaba, MD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
Editor's note: David M. Gaba, MD, is a Professor of Anesthesia at the Stanford University School of
Medicine. An international leade…
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/web-mm/watch-warfarin
December 01, 2013 - SPOTLIGHT CASE
Watch the Warfarin!
Citation Text:
Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNot…
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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - SPOTLIGHT CASE
Low on the Totem Pole
Citation Text:
Wachter R. Low on the Totem Pole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - Communication Error in a Closed ICU
Citation Text:
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
December 22, 2018 - SPOTLIGHT CASE
Engaging Seriously Ill Older Patients in Advance Care Planning
Citation Text:
Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. …
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psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
August 02, 2015 - SPOTLIGHT CASE
Delay in Initiating Antibiotics Results in Fatal Error
Citation Text:
Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. 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/web-mm/check-twice-transport-once
March 15, 2023 - Check Twice, Transport Once
Citation Text:
DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
November 27, 2019 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities
Citation Text:
Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…
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psnet.ahrq.gov/curated-library/diagnostic-error
November 03, 2025 - Breadcrumb
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Diagnostic Error
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Created By: Karen Cosby, AHRQ
Date Created: May 8, …
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psnet.ahrq.gov/web-mm/its-sarah-not-stephen
January 01, 2015 - SPOTLIGHT CASE
It's Sarah, Not Stephen!
Citation Text:
Sarkar U. It's Sarah, Not Stephen!. 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/emergency-error
January 18, 2013 - SPOTLIGHT CASE
Emergency Error
Citation Text:
Symons NRA. Emergency Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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