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psnet.ahrq.gov/node/49815/psn-pdf
December 01, 2017 - Over-the-Counter Oversight
December 1, 2017
Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/over-counter-oversight
The Case
A 56-year-old man was evaluated in the burn clinic for a second-degree burn on his chest. Although
portions of his skin we…
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psnet.ahrq.gov/node/49423/psn-pdf
November 01, 2003 - The Missing Suction Tip
November 1, 2003
Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/missing-suction-tip
Case Objectives
Identify the risk factors for retained foreign bodies.
Understand methods used to prevent and identify retained foreign bodies.
Apprecia…
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psnet.ahrq.gov/web-mm/paradoxical-pulse
May 01, 2013 - Paradoxical Pulse
Citation Text:
Roy CL. Paradoxical Pulse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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…
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psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering
Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019
View more articles from the same authors.
Citation Text:
Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…
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psnet.ahrq.gov/node/49718/psn-pdf
January 01, 2015 - Too Much, Too Fast
September 1, 2014
Tuot D. Too Much, Too Fast. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/too-much-too-fast
The Case
A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for
fever, tachycardia, and increased respiratory secretions. H…
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psnet.ahrq.gov/node/49646/psn-pdf
February 01, 2012 - Poorly Advanced Directives
February 1, 2012
Anderson WG. Poorly Advanced Directives. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/poorly-advanced-directives
The Case
Cared for at home by his wife and family, an 82-year-old man with multiple chronic medical conditions
described his overall health as decli…
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psnet.ahrq.gov/node/49776/psn-pdf
November 01, 2016 - Continuity Errors in Resident Clinic
November 1, 2016
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
The Case
A 32-year-old woman presented to internal medicine clinic for evaluation of headaches and difficulty
concentrating. …
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psnet.ahrq.gov/node/49569/psn-pdf
September 01, 2008 - Where's the Feeding Tube?
September 1, 2008
Metheny NA, Meert KL. Where's the Feeding Tube? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wheres-feeding-tube
The Case
A 13-year-old boy was involved in a motor vehicle collision and experienced a traumatic brain injury.
Because of the injuries, he was unabl…
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psnet.ahrq.gov/node/33685/psn-pdf
May 01, 2009 - In Conversation with…William B. Weeks, MD, MBA
May 1, 2009
In Conversation with…William B. Weeks, MD, MBA. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
Editor's note: William B. Weeks, MD, MBA, is Associate Professor of Psychiatry and of Community and
Family M…
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psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
May 01, 2012 - Situational Awareness and Patient Safety
Citation Text:
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
August 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Diagnostic Errors Case Studies
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Created By: Maria Mirica, PRIDE Group
…
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - Patient Safety 101
Citation Text:
Patient Safety 101. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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D…
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psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation
March 27, 2024 - Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation
Citation Text:
Kulig CE, Ebong IA. Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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…
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - Medication Reconciliation Pitfalls
Citation Text:
Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/perspective/patient-safety-primary-care
January 31, 2020 - Annual Perspective
Patient Safety in Primary Care
February 21, 2020
View more articles from the same authors.
Citation Text:
Schiff G, Hall KK, Fitall E. Patient Safety in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…
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psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
July 01, 2012 - "Superficial" Report Leads to "Deep" Problem
Citation Text:
Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.308_slideshow.ppt
October 01, 2013 - PowerPoint Presentation
Spotlight Case
It's Sarah, not Stephen!
1
This presentation is based on the October 2013 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Urmimala Sarkar, MD, MPH, University of California at San Francisco
Editor, AHRQ WebM&…
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psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD
August 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/perspective/conversation-rebecca-smith-bindman-md
October 01, 2013 - In Conversation With… Rebecca Smith-Bindman, MD
October 1, 2013
Also Read an Essay
Citation Text:
In Conversation With… Rebecca Smith-Bindman, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - Identifying Adverse Events Not Present on Admission: Can We Do It?
James M. Naessens, ScD | October 1, 2008
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Naessens JM. Identifying Adverse Events Not Present on Admission: Can W…