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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 1 - 11 of 11 Results
Curated Libraries
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January 19, 2023
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WebM&M Case
August 31, 2022
A 49-year-old woman was referred by per primary care physician (PCP) to a gastroenterologist for recurrent bouts of abdominal pain, occasional vomiting, and diarrhea. Colonoscopy, esophagogastroduodenoscopy, and x-rays were interpreted as normal, and the patient was reassured that her symptoms should abate. The patient was seen by her PCP and visited the Emergency Department (ED) several times over the next six months. At each ED visit, the patient’s labs were normal and no imaging was performed.
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WebM&M Case
December 23, 2020
After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy.
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WebM&M Case
August 10, 2019
Referred to urology for a 5-year history of progressive urinary frequency, nocturnal urination, and difficulty initiating a stream, a man had been reluctant to seek care for his symptoms because his father had a "miserable" experience with treatment for the same condition. A physician assistant saw him at that first visit and ordered a PSA test (despite the patient's expressed views against PSA testing) and cystoscopy (without explaining why it was needed), and urged the patient to self-catheterize (without any instructions on how to do so).
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WebM&M Case
November 1, 2016
After a motor vehicle collision, a patient with headaches and difficulty concentrating visited the internal medicine clinic. The covering resident diagnosed postconcussive syndrome and prescribed amitriptyline. The patient returned several days later with persistent symptoms. She saw a different resident, who ordered an MRI and referred her to neurology but mistakenly made the referral to the neuromuscular, rather than headache, clinic. With continued severe headaches, the patient returned a third time and saw her primary resident provider, who referred her to the correct neurology clinic.
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WebM&M Case
July 1, 2011
A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.
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WebM&M Case
October 1, 2008
An elderly, non–English-speaking man with diabetes was admitted to the hospital twice in 8 days due to hypoglycemia. At discharge, the patient was instructed not to take any antidiabetic medications. In between hospitalizations, he saw his primary care physician, who restarted an antidiabetic medication.
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WebM&M Case
September 1, 2008
After several pediatric visits, parents of a newborn with low output and weight loss contact a lactation consultant, who discovered that ankyloglossia (tongue-tie) was preventing the infant from receiving adequate intake from breastfeeding.
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WebM&M Case
December 1, 2004
Feeling "weak" late at night, a patient calls his doctor's office. The covering physician misses a few clues, which might have prompted a different plan.
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WebM&M Case
February 1, 2004
A physician who does not accept Medicaid turns away a woman needing evaluation for 2 years of profuse vaginal bleeding. She later presents to the ED, where examination reveals invasive cervical cancer.
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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.
