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The PSNet Collection: All Content
The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
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Displaying 18701 - 18720 of 18731 Results
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WebM&M Case
September 1, 2003
A patient dies from infection and complications months after surgery; a retained sponge is found at autopsy.
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WebM&M Case
September 1, 2003
Failure to shake a bottle leads to a toxic level of carbamazepine in a patient being treated for seizure disorder.
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WebM&M Case
July 1, 2003
A patient asks to be "DNR" because she misunderstood a vague discussion of resuscitation.
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WebM&M Case
July 1, 2003
A physician in the ED mistakenly glues a child's eye shut when attempting to close a facial wound with skin adhesive.
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WebM&M Case
July 1, 2003
Following hysterectomy, a PCA pump is mistakenly continued in a woman suffering an adverse reaction to morphine, noticed only when her respiratory status set off an alarm.
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WebM&M Case
July 1, 2003
An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.
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WebM&M Case
July 1, 2003
Inadequate monitoring and management of warfarin places patient at significant risk of harm.
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WebM&M Case
June 1, 2003
En route to x-ray, suicidal patient attempts to hang herself in washroom.
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WebM&M Case
June 1, 2003
A boy given an overdose of nifedipine rather than its extended-release (XL) form suffers dangerous hypotension.
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WebM&M Case
June 1, 2003
A woman was told she miscarried, even though she was still pregnant.
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WebM&M Case
June 1, 2003
Antibiotics continued in a patient with no clear source of infection for 3 weeks results in hospital-acquired superinfections.
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WebM&M Case
June 1, 2003
Abdominal pain misdiagnosed in an ED patient leads to ruptured appendix, multiple complications, and prolonged hospitalization.
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WebM&M Case
May 1, 2003
Suicidal patient who admits having firearm refuses to remove gun from home for nearly 3 months.
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WebM&M Case
May 1, 2003
An infant codes due to pulmonary emboli after a central line flush.
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WebM&M Case
May 1, 2003
A blood-soaked BP cuff used on one trauma patient is re-used on the next trauma patient, with no regard to universal precautions.
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WebM&M Case
May 1, 2003
A chest x-ray incorrectly read as pleural effusion, rather than lung collapse, leads to iatrogenic pneumothorax following thoracentesis.
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WebM&M Case
May 1, 2003
A woman is given methotrexate prematurely for suspected ectopic pregnancy and ultimately has salpingectomy.
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WebM&M Case
April 1, 2003
Antipsychotic, rather than antihistamine, mistakenly dispensed to woman with bipolar disorder with new urticaria.
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WebM&M Case
April 1, 2003
A boy received an overdose of phenytoin due to ambiguous use of abbreviations.
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WebM&M Case
April 1, 2003
Incorrect dating criteria in a woman late entering prenatal care nearly leads to induction of a pre-term infant.
