McLean C. AHRQ WebM&M [serial online]. March 2005.
At a routine clinic visit, screening labs are sent for a man with HIV. Not notified of the results, he assumes they are normal. One month later, he develops a classic syphilitic rash.
Free full text
Urine a Tough Position.
Gandhi TK. AHRQ WebM&M [serial online]. October 2003.
Not a Miscarriage.
Learman LA. AHRQ WebM&M [serial online]. June 2003.
The Dropped Lung.
Heffner JE. AHRQ WebM&M [serial online]. May 2003.
Adams JG. AHRQ WebM&M [serial online]. June 2003.
View all related resources...
Find Related Resources by...
Setting of Care
Ambulatory Clinic or Office
Missed or Critical Lab Results
Noncognitive Errors ("Slips & Lapses")
Cognitive Errors ("Mistakes")
Approach to Improving Safety
Communication between Providers
Laboratory Result Tracking Improvement
Agency for Healthcare Research and Quality (AHRQ)
Produced for the
Agency for Healthcare Research and Quality
team of editors
University of California, San Francisco
with guidance from a prominent
. The AHRQ PSNet site was designed and implemented by Silverchair.
Contact AHRQ PSNet
Terms & Conditions
Freedom of Information Act
The White House
USA.gov: U.S. Government Official Web Portal
Agency for Healthcare Research and Quality • 540 Gaither Road Rockville, MD 20850 • Telephone: (301) 427-1364