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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - [Limited by the constraints of the plastic mannequin simulator, the case involves a 6-year-old instead … Videos
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Poor Communication … Commentary
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - The Case
An 83-year-old man with chronic kidney disease and end-stage congestive heart failure (CHF … validated symptom assessment instruments such as the Edmonton Symptom Assessment Score.( 14 ) The case description … Objectives
The Case
The Commentary
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Related Resources From the Same Author
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - thinking List the cardinal dimensions of clinical decision-making Case & Commentary: Part 1 A 62-year-old … In a 62-year-old female with crushing chest pain, most physicians would choose an acute coronary syndrome … Although this description has long been considered a hallmark of myocardial infarction (MI), studies … Commentary: Part 3
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psnet.ahrq.gov/web-mm/e-prescribing-e-error
February 03, 2021 - Case & Commentary- Part 1:
A 63-year-old man with multiple medical problems was seen by his primary … Part 1:
Case & Commentary- Part 2:
References
Related Resources From the Same Author … December 31, 2014
From physician intent to the pharmacy label: prevalence and description
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - Case & Commentary: Part 1
A 10-year-old child from India presented to his pediatrician's office for … takes place, patients first want an explicit, jargon-free statement that an error occurred and a basic description … : Part 2
Case & Commentary: Part 3
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psnet.ahrq.gov/node/49570/psn-pdf
October 01, 2008 - Case & Commentary: Part 1
A 70-year-old man with type II diabetes and chronic kidney disease was admitted … and Community
Even as we discuss the holy grail of an interoperable EHR, it is worth noting that the description
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psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
August 01, 2007 - So when they read in the paper that 50,000 to 100,000 people were being killed in hospitals each year … them in the eye and say, the board is expecting us to come back in 3 months with a plan and within a year … hearing about the rates of central line infections, but they're also hearing storiesstories about the 30-year-old … In the last year or two, we've seen three fairly large studies of boards and how they work and how they … hospitals championed improved stroke care to the governing board, it resulted in a highly successful year-long
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psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
March 27, 2024 - First, Beth Israel Deaconess has a 30-year culture of innovation: Doctors creating software for doctors … That's what 26-year-olds in their garages are going to be working on for the next 10 years, and that's … JH : I spend $5 million a year on cyber security. … Every year, I identify 100 new risks and mitigate the top risks by buying new technology, changing policy … For example, this year we changed every doctor's experience on every device all over the world.
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psnet.ahrq.gov/node/33789/psn-pdf
August 01, 2015 - The note began at the time of Hippocrates as a narrative description of what the patient
was saying. … A wise person once said: we virtually always overestimate what we can do in a year and underestimate … Silicon Valley has figured out in the last year or two that health care is the only
part of the economy
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psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
July 01, 2006 - The next year I was asked to co-chair an IHI collaborative. … The simple description is that if you take human beings with their innate frailties and put them into
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psnet.ahrq.gov/node/49707/psn-pdf
April 01, 2014 - https://psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
The Case
A 42-year-old man with acquired … Iatrogenic Cushing's syndrome in
HIV-infected patients receiving ritonavir and inhaled fluticasone: description
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psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - The Cases
Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) with … Case #2: A 49-year-old male patient with history of poorly controlled type 1 diabetes, homelessness, … Commentary
Background
Take Home Points
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Related Resources From the Same Author
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psnet.ahrq.gov/node/49789/psn-pdf
April 01, 2017 - The Case
A 94-year-old woman with history of congestive heart failure (CHF), hypertension, and gout … Notably, in the last year
the patient had been hospitalized 5 times for CHF exacerbations or pneumonia
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psnet.ahrq.gov/web-mm/critical-opportunity-lost
February 17, 2017 - The Case A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. … Sections
The Case
The Commentary
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Related Resources From the Same Author
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psnet.ahrq.gov/node/49538/psn-pdf
June 01, 2007 - https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results
The Case
A healthy 52-year-old woman volunteered … Nov-Dec 2006;6:28-30; author reply W10-22. [go to PubMed]
8.
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psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
January 01, 2016 - , and in our peer review program, we were seeing all sorts of diagnostic errors that kept recurring year … after year after year. … The best estimate from autopsy studies is that there are 40,000 to 80,000 deaths a year from diagnostic … MG : I have to tell you one of the most pleasurable things I did this year was to read your book on … correct or timely diagnosis based on the available evidence, regardless of patient harm.( 5 ) This description
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psnet.ahrq.gov/node/50949/psn-pdf
February 26, 2020 - psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
The Case
Case #1:
A 56-year-old … Case #2:
A 59-year-old man was treated for a suspected myocardial infarction due to erroneous cardiac … In one study, the practice of collecting rainbow draws was attributed
to 275 L of blood wasted per year
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
May 01, 2009 - But it would have a 5- or 8-year endpoint, which allows the organization to right-size without bankruptcy
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psnet.ahrq.gov/node/49587/psn-pdf
May 01, 2009 - https://psnet.ahrq.gov/web-mm/missing-trauma
The Case
A 54-year-old woman collapsed behind the counter
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - The Case A 56-year-old man with insulin-dependent diabetes, hypertension, and chronic kidney disease … This 56-year-old patient in the ICU has risk for complications due to prolonged mechanical ventilation … The description of the processes they applied is a resource for institutions that are implementing comprehensive … The Case
The Commentary
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