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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.
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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/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/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/curated-library/diagnostic-errors-case-studies
August 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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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/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/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx
Spotlight
A Complicated Course: Severe Alcohol Withdrawal with
Dexmedetomidine Infusion
Source and Credits
• This presentation is based on the July 2023 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
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psnet.ahrq.gov/perspective/patient-safety-home-dialysis
April 28, 2021 - Patient Safety in Home Dialysis
April 28, 2021
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Morfín JA, Fitall E, Hall KK, et al. Patient Safety in Home Dialysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/node/49714/psn-pdf
August 21, 2014 - National trends in ambulatory visits and antibiotic
prescribing for skin and soft-tissue infections.
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psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
March 27, 2024 - implications for clinical practice and the potential use of healthcare information technology to improve prescribing
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - fentanyl, alfentanil, and methadone (for strong pain).( 16,17 )
Many different errors may arise in prescribing
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psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
November 27, 2019 - October 18, 2023
Are physician assistants able to correctly identify prescribing errors
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psnet.ahrq.gov/node/33759/psn-pdf
October 01, 2012 - with primary care PBRNs has focused on developing and
implementing strategies to reduce inappropriate prescribing
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - WebM&M Cases
The Lost Start Date: an Unknown Risk of E-prescribing
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
January 31, 2024 - resistance) outweighed the risk of treating the individual unnecessarily in these situations (i.e., prescribing
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psnet.ahrq.gov/node/848107/psn-pdf
April 26, 2023 - resistance) outweighed the risk of treating the individual unnecessarily
in these situations (i.e., prescribing
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psnet.ahrq.gov/node/49872/psn-pdf
August 08, 2019 - Spinal Epidural Abscess
August 8, 2019
Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spinal-epidural-abscess
The Case
A 30-year-old woman with a history of prior spine surgery presented to the emergency department with a
few days of progressive low back pain. She…
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psnet.ahrq.gov/node/49495/psn-pdf
December 01, 2005 - Low on the Totem Pole
December 1, 2005
Wachter R. Low on the Totem Pole. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/low-totem-pole
Case Objectives
Understand the concept of authority gradient
List steps that can be taken to increase communication across an authority gradient
Consider the current cultu…
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psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
January 24, 2018 - Primary Workaround, Secondary Complication
Citation Text:
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Google Scholar B…
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psnet.ahrq.gov/node/49706/psn-pdf
January 01, 2015 - Clostridium Difficile Relapse Secondary to Medication
Access Issue
April 1, 2014
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
The Case
A 24-year-old wom…