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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 - 20 of 23 Results
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WebM&M Case
December 23, 2020
A 65-year-old man with metastatic cancer and past medical history of schizophrenia, developmental delay, and COPD was admitted to the hospital with a spinal fracture. He experienced postoperative complications and continued to require intermittent oxygen and BIPAP in the intensive care unit (ICU) to maintain oxygenation. Upon consultation with the palliative care team about goals of care, the patient with telephonic support of his long time caregiver, expressed his wish to go home and the palliative care team, discharge planner, and social services coordinated plans for transfer home. Altho
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WebM&M Case
February 1, 2019
To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid.
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WebM&M Case
January 1, 2019
A woman with a history of psychiatric illness presented to the emergency department with agitation, hallucinations, tachycardia, and transient hypoxia. The consulting psychiatric resident attributed the tachycardia and hypoxia to her underlying agitation and admitted her to an inpatient psychiatric facility. Over the next few days, her tachycardia persisted and continued to be attributed to her psychiatric disease. On hospital day 5, the patient was found unresponsive and febrile, with worsening tachycardia, tachypnea, and hypoxia; she had diffuse myoclonus and increased muscle tone.
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WebM&M Case
January 1, 2016
Admitted to the hospital for chemotherapy, a man with leukemia and diabetes arrived on the medical unit on a busy afternoon and waited until his room was ready. The nurse who checked him in assumed that his admitting orders were completed on the previous shift. That night, the patient took his own insulin from home without a meal and experienced a preventable episode of hypoglycemia.
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WebM&M Case
March 1, 2015
A man with suspected renal cell carcinoma seen on CT in the right kidney was transferred to another hospital for surgical management. The imaging was not sent with him, but hospital records, which incorrectly documented the tumor as being on the left side—were. The second hospital did not obtain repeat imaging, and the surgeon did not see the original CT prior to removing the wrong kidney.
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WebM&M Case
February 1, 2013
After her discharge, providers were unable to reach a young woman hospitalized for heavy vaginal bleeding, whose chlamydia culture returned positive. The delay in treatment led to infection of her fallopian tubes and required hospitalization for intravenous antibiotics.
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WebM&M Case
June 1, 2012
An elderly woman was transferred to a tertiary hospital for surgical repair of hip fracture, without complete information or records. The receiving surgeons were not informed that she had a cardiac arrest during induction of anesthesia at the community hospital. Surgery proceeded, but the patient died a few days later.
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WebM&M Case
March 1, 2012
A woman hospitalized with community-acquired pneumonia was discharged home on antibiotics. Over the next few days, her symptoms worsened, but she was unable to obtain an appointment with her primary physician. The hospital called the patient that day to follow up, determined that she needed a different antibiotic, and prevented a readmission.
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WebM&M Case
September 1, 2011
Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.
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WebM&M Case
July 1, 2011
Following hospitalization for community-acquired pneumonia, an elderly man with a history of dementia, falls, and atrial fibrillation is discharged on antibiotics but no changes to his anticoagulation medication. One week later, the patient’s INR was dangerously high.
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WebM&M Case
November 1, 2010
A man returns to the emergency department 11 days after hospital discharge in worsening condition. With no follow-up on a urine culture and sensitivity sent during his hospitalization, the patient had been taking the wrong antibiotic for a UTI.
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WebM&M Case
December 1, 2009
A man with a history of IV drug use is admitted to the hospital and found to have an epidural abscess with surrounding osteomyelitis. Although the treatment plan required weeks of IV antibiotics, the patient (who fought with the nursing staff and threatened to leave against medical advice [AMA]) was discharged after 2 weeks on oral antibiotics. His condition worsened, and he returned 3 weeks later, but he ultimately left AMA and was lost to follow-up.
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WebM&M Case
March 21, 2009
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
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WebM&M Case
November 1, 2008
Due to lack of communication during shift change, an infant's transfer to a higher level of care is delayed. The infant develops respiratory distress, prompting a call to the rapid response team and transfer to the ICU.
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WebM&M Case
December 1, 2007
An inpatient missing from his room is found several hours later outside the emergency department. Despite having arrived at the ED in a hospital gown with an inpatient ID bracelet, the patient is treated in the ED and discharged.
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WebM&M Case
October 1, 2007
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
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WebM&M Case
September 1, 2007
Hospitalized for surgery, a woman with a history of seizures was given an overdose of the wrong medicine due to multiple errors, including an inaccurate preadmission medication list, failure to verify medication history, and uncoordinated information systems.
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WebM&M Case
September 1, 2006
An elderly man was admitted to the hospital for pacemaker placement. Although the postoperative chest film was normal, the patient later developed shortness of breath. Over the course of several nursing and physician shift changes and signouts, results of a follow-up stat x-ray are not properly obtained, delaying discovery of the patient's pneumothorax.
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WebM&M Case
August 1, 2006
A man with paraplegia was admitted to the hospital, but the admitting physician, night float resident, and daytime team all "deferred" examination of the genital area. The patient was later discovered to have life-threatening necrotizing fasciitis of this area.
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WebM&M Case
July 1, 2006
An elderly woman was transported to CT with no medical escort and an inadequate oxygen supply. She died later that day.
