Patient Safety Systems

Creating a safer health care system for patients and providers.

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Prior AHRQ WebM&M Highlighted Cases

Injury Case – This prior case from PSNet notes the difficulty in diagnosing certain diseases after injury.

Radiology Case – Prior Case from PSNet about a problem getting a reading on a radiology test. At first glance it appears that security concerns made it impossible for two different hospitals to communicate about a radiology test done on a patient. But the story is a little more complicated.

A Leaving Against Medical Advice Case – This is a prior highlighted case that describes a patient who leaves against medical advice. When patients leave this way medical providers are often frustrated and feel that the patient is taking the risk. But we are the ones that truly understand the risks of medical conditions that might worsen. We should treat these cases very carefully.

This is a Copy and Paste Case – It reminds us of the all to easy and common concerns that come from the copy and paste function.

This is a case of Medication Error – This case reminds us that medication labels on all medications and in all environments are critical to prevent devastating medications.

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Twitter handle (yes I still call it twitter)- @VASafetyDoc

or if you are on BlueSky – @rrhemp.bsky.social

or Spoutable – @RRHemp

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Send an email healthcarechasm@mac.com

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  • Systems For Patient Safety
  • Blog
  • About This Site
  • Resources
  • Quality and Safety Presentations
    • Case Studies and Presentations – COMING SOON
    • Prior AHRQ WebM&M Highlighted Cases
  • Safety Posts for Clinicians
    • Safety Posts for patients and families
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