-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
August 01, 2015 - PowerPoint Presentation
Spotlight
Privacy or Safety?
1
This presentation is based on the July/August 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John D. Halamka, MD, MS, Beth Israel Deaconess Medical Center; and Deven McGraw, JD, MPH, LLM…
-
psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…
-
psnet.ahrq.gov/node/49448/psn-pdf
June 01, 2004 - Listen to the Family
June 1, 2004
Campbell D. Listen to the Family. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/listen-family
The Case
Vascular surgery was consulted for placement of a dialysis catheter in a patient on the medical floor. The
surgical resident examined the patient, an elderly woman with …
-
psnet.ahrq.gov/node/60169/psn-pdf
March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration
errors in the operating room.
March 25, 2020
Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…
-
psnet.ahrq.gov/node/49839/psn-pdf
August 01, 2018 - Mixup Beyond the Medication Label
August 1, 2018
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
The Case
An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another
hospi…
-
psnet.ahrq.gov/node/49578/psn-pdf
January 01, 2009 - Hospital Admission Due to High-Dose Methotrexate Drug
Interaction
January 1, 2009
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
The Case
A 40-year-old wo…
-
psnet.ahrq.gov/node/33679/psn-pdf
January 01, 2009 - Disclosure of Medical Error
January 1, 2009
Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/disclosure-medical-error
Perspective
Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts
advocate that greater discl…
-
psnet.ahrq.gov/node/49635/psn-pdf
September 01, 2011 - Central, not Epidural
September 1, 2011
Simmons D. Central, not Epidural. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/central-not-epidural
The Case
A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively,
he was awake, alert, and oriented to time, place,…
-
psnet.ahrq.gov/node/49867/psn-pdf
July 02, 2019 - Diuretics and Electrolyte Abnormalities
July 2, 2019
Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
Case Objectives
Recognize that thiazide diuretics can lead to serious adverse events.
State how commonly used t…
-
psnet.ahrq.gov/node/49701/psn-pdf
February 01, 2014 - An Easily Forgotten Tube
February 1, 2014
Ousey K. An Easily Forgotten Tube. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/easily-forgotten-tube
The Case
A 45-year-old man was admitted to the intensive care unit (ICU) for acute liver failure secondary to alcohol
abuse. His illness was complicated by acute…
-
psnet.ahrq.gov/node/33749/psn-pdf
April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety?
April 1, 2013
Fletcher KE, Reed DA. Are Residency Duty Hour Rules Improving Patient Safety? PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
Perspective
Introduction
The Accreditation Council f…
-
psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - Suicide Risk in the Hospital
May 1, 2018
Mills PD. Suicide Risk in the Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/suicide-risk-hospital
The Case
A 37-year-old woman with a past medical history of depression, anxiety, and posttraumatic stress disorder
presented to the emergency department (ED)…
-
psnet.ahrq.gov/node/49868/psn-pdf
July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With
Dementia
July 2, 2019
Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
The Case
An 86-year-old man with neurode…
-
psnet.ahrq.gov/node/33844/psn-pdf
October 01, 2017 - Health Care Worker Presenteeism: A Challenge for Patient
Safety
October 1, 2017
Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
Perspective
Introduction
Health care–as…
-
psnet.ahrq.gov/node/49619/psn-pdf
February 01, 2011 - Paradoxical Pulse
February 1, 2011
Roy CL. Paradoxical Pulse. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/paradoxical-pulse
The Case
An 80-year-old man with paroxysmal atrial fibrillation and symptomatic bradycardia underwent successful
pacemaker placement as an outpatient. The patient was restarted on …
-
psnet.ahrq.gov/node/49842/psn-pdf
September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric
Emergency Equipment
September 1, 2018
Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet
[internet]. 2018.
https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
The Case
As part of…
-
psnet.ahrq.gov/node/49390/psn-pdf
February 01, 2003 - Flying Object Hits MRI
February 1, 2003
Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/flying-object-hits-mri
The Case
A child was brought to the Magnetic Resonance Imaging (MRI) room for a brain scan. Accompanied by an
anesthesiologist, the child was receiving…
-
psnet.ahrq.gov/node/867980/psn-pdf
March 25, 2025 - Not All Headaches are Due to Migraine: Red Flags, Don’t
Miss Diagnoses, and Diagnostic Pitfalls
March 25, 2025
Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic
Pitfalls. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-fla…
-
psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
September 01, 2006 - March 27, 2024
Patient Safety Innovations
Remote Response
-
psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
March 29, 2023 - attempt (e.g., in major depressive disorder ) if the patient’s intent was death, or it can occur in response