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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 - 9 of 9 Results
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.
WebM&M Case March 1, 2012
Following biopsies for two skin lesions on his left cheek, a patient was sent to an outside surgeon for excision of squamous cell carcinoma. Although the referral included a description and diagram, the wrong lesion was removed.
WebM&M Case August 21, 2007
A patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed.
WebM&M Case May 1, 2006
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
WebM&M Case December 1, 2004
Despite a "time out" and having his leg marked by the surgeon, a patient comes perilously close to having surgery on the wrong leg.
WebM&M Case February 1, 2004
Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.
WebM&M Case January 1, 2004
During a hernia repair, surgeons decide to remove a patient's hydrocele, spermatic cord, and left testicle—without realizing that his right testicle had been removed previously.
WebM&M Case October 1, 2003
Trusting his memory more than the chart, a surgeon directs a resident to remove the wrong side on a patient with unilateral vulvar cancer.