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psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
May 08, 2019 - Miscommunication in the OR Leads to Anticoagulation Mishap
Citation Text:
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Forma…
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psnet.ahrq.gov/node/49536/psn-pdf
May 01, 2007 - On the Other Hand
May 1, 2007
Henneman EA. On the Other Hand. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/other-hand
The Case
A young woman with Takayasu's arteritis presented to the hospital with severe abdominal pain. The patient
had been diagnosed with Takayasu's a decade earlier. The disease results…
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psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3
Citation Text:
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibTeX EndNote X3…
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psnet.ahrq.gov/node/49493/psn-pdf
November 01, 2005 - Infused, Not Ingested
November 1, 2005
Foley M. Infused, Not Ingested. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/infused-not-ingested
The Case
A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering
contrast, an unfamiliar task for this particular nurse. Rathe…
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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/49466/psn-pdf
October 14, 2004 - Hard to Swallow
October 1, 2004
Driver J. Hard to Swallow. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/hard-swallow
The Case
An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic
attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
August 10, 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/web-mm/nothing-called-small-surgery
February 01, 2023 - Some practitioners have advocated against the use of these digital blocks in the emergency room setting
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psnet.ahrq.gov/web-mm/pregnant-danger
January 12, 2011 - The Commentary
This case illustrates the frequent challenges that practitioners and institutions face
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psnet.ahrq.gov/web-mm/empty-bag
June 01, 2018 - It also suggests making it easy for practitioners to map the IV container and associated tubing.
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psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
December 01, 2014 - who perform many procedures achieve low complication rates.( 15,16 ) This highlights a central point: practitioners
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psnet.ahrq.gov/web-mm/slippery-slide-life
January 21, 2017 - professionals have trained by engaging in rigorous classroom activities followed by observing skilled practitioners
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psnet.ahrq.gov/node/33770/psn-pdf
August 01, 2014 - Nurse practitioners, nurses, and
medical assistants are also part of a team, such that a group of clinical
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - In 2016, a survey of 503 nurses, physicians, IT practitioners, and CFOs/financial operations experts
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psnet.ahrq.gov/node/49657/psn-pdf
July 01, 2012 - who perform many procedures achieve low complication
rates.(15,16) This highlights a central point: practitioners
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psnet.ahrq.gov/node/49491/psn-pdf
September 01, 2005 - support their use.(23,24) The
American Academy of Pediatrics promotes the use of periodic mock codes for practitioners
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psnet.ahrq.gov/node/49846/psn-pdf
November 01, 2018 - defined in the British Journal of Psychology as "The formal provision, by
senior/qualified health practitioners
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psnet.ahrq.gov/curated-library/diagnostic-safety-improvement
July 21, 2025 - focus on physicians and involve a wide range of professionals, including pathologists, allied health practitioners
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psnet.ahrq.gov/web-mm/dissecting-presentation
May 05, 2021 - Better education of emergency practitioners with emphasis on the pitfalls in chest pain evaluation and
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psnet.ahrq.gov/node/33766/psn-pdf
May 01, 2014 - DP: Auditing is performed using infection control practitioners monitoring practices in different wards