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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - October 31, 2011
Opioid prescribing for acute pain management in children and adolescents
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psnet.ahrq.gov/web-mm/emergent-triage-miss
March 06, 2015 - June 27, 2018
Early prescribing outcomes after exporting the EQUIPPED medication safety
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - February 23, 2011
Reducing prescribing errors in hospitalized children on the ketogenic
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psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn
April 28, 2021 - In Conversation With... José A, Morfín, MD, FASN
April 28, 2021
Also Read the Essay
Citation Text:
In Conversation With.. José A, Morfín, MD, FASN. PSNet [internet]. 2021.In Conversation With... José A, Morfín, MD, FASN. PSNet [internet]. Rockville (MD): Agency f…
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psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
January 01, 2021 - Spotlight
Spotlight
An Inadvertent Bolus of Norepinephrine
Source and Credits
• This presentation is based on the May 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarina Fazio, PhD, RN, Emma Blackmon, PhD,
RN, Amy Doroy, PhD,…
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Spotlight
Too Many Cooks in the Kitchen
Source and Credits
• This presentation is based on the August 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Richard P. Dutton, MD, MBA
o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
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psnet.ahrq.gov/node/49538/psn-pdf
June 01, 2007 - Abnormal Volunteer Results
June 1, 2007
Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results
The Case
A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent
magnetic resonance imaging (MRI) of her abdo…
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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.
Copy Citation
Format:
Google Scholar BibTeX EndN…
-
psnet.ahrq.gov/node/49518/psn-pdf
August 01, 2006 - It's All in the Syringe
August 1, 2006
Weingart SN. It's All in the Syringe. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/its-all-syringe
The Case
A 33-year-old man with type 2 diabetes presented to his physician's office to discuss his diabetes
management. The patient admitted not taking his medications…
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psnet.ahrq.gov/sites/default/files/2022-12/spotlight_case_strongyloides_final_11.21.22.pdf
January 01, 2022 - Spotlight
Spotlight
Strongyloides: A Hidden Traveler
and Potentially Lethal Missed
Diagnosis
Source and Credits
• This presentation is based on the November 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Narath Carlile MD MPH,…
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
November 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Diagnostic Errors Case Studies
Download
Share
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Created By: Maria Mirica, PRIDE Group
…
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psnet.ahrq.gov/node/33695/psn-pdf
April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest
for Transparency in U.S. Hospitals' Patient Safety
Performance
April 1, 2010
Roberts LL, Ward MM, Evans TC. The Role of the National Quality Forum (NQF) in the Quest for
Transparency in U.S. Hospitals' Patient Safety Performance. PSNet [internet]. 2010.
ht…
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psnet.ahrq.gov/web-mm/critical-opportunity-lost
February 17, 2017 - Critical Opportunity Lost
Citation Text:
Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…
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psnet.ahrq.gov/node/49625/psn-pdf
May 01, 2011 - Pocket Syringe Swap
May 1, 2011
Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/pocket-syringe-swap
The Case
A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for
postoperative pain management. Surgery proceeded uneventfully under…
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psnet.ahrq.gov/node/72693/psn-pdf
January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room
– Mixing Up the Ampules
January 29, 2021
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
The Case
A…
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psnet.ahrq.gov/node/49674/psn-pdf
December 01, 2012 - Preventing PICC Complications: Whose Line Is It?
December 1, 2012
Moureau N. Preventing PICC Complications: Whose Line Is It? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
The Case
A 55-year-old woman with myasthenia gravis, hypertension, and hypothyroidism prese…
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psnet.ahrq.gov/node/49710/psn-pdf
May 01, 2014 - Discontinued Medications: Are They Really
Discontinued?
May 1, 2014
Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued? PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
The Case
A 69-year-old man with a history of chronic atrial f…
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psnet.ahrq.gov/classics
August 01, 2023 - Dispensing Errors
(2)
Monitoring Errors and Failures
(1)
Ordering/Prescribing
-
psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - WebM&M Cases
The Lost Start Date: an Unknown Risk of E-prescribing
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - March 24, 2021
WebM&M Cases
Multiple Levels Involved in Prescribing