-
psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
November 16, 2022 - A retrospective review of Aspergillus cultures from the same OR and PICU did not find any other cases … Aspergillosis after cardiac surgery has a reported mortality rate of 93%. 1 Only a few pediatric cases … contaminated equipment, and environmental air associated with construction. 1,6,7 Although in many cases … Although they did not find any other cases of postoperative Aspergillus, this review could have been … April 22, 2013
WebM&M Cases
Informed or Misled?
-
psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - and commentaries from their monthly discussions of diagnosis error cases to PSNet. … December 23, 2020
WebM&M Cases
Multiple Missed … December 23, 2020
WebM&M Cases
Misdiagnosis of … February 9, 2011
WebM&M Cases
All in the History … February 1, 2004
WebM&M Cases
The Dropped
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psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - May 16, 2022
WebM&M Cases
Challenges of Diabetes … Preventable Rash
March 1, 2005
WebM&M Cases … June 16, 2019
WebM&M Cases
E-cigarette Explosion in a … Handoff
March 1, 2004
WebM&M Cases
The 2-Week … Itch
April 1, 2003
WebM&M Cases
Flying Object
-
psnet.ahrq.gov/node/844773/psn-pdf
September 11, 2019 - How Veterans Affairs failed to stop a pathologist who
misdiagnosed 3,000 cases. … https://psnet.ahrq.gov/issue/how-veterans-affairs-failed-stop-pathologist-who-misdiagnosed-3000-cases … https://psnet.ahrq.gov/issue/how-veterans-affairs-failed-stop-pathologist-who-misdiagnosed-3000-cases
-
psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - Type II cases may develop in young, healthy patients with no predisposing factors. 2 Type III includes … Graber et al. analyzed 100 cases from an Internal Medicine service to classify and quantify the types … Sepsis was the leading cause among the infectious cases. … Analysis of these cases identified clinical judgment problems as a contributing factor (85% of cases) … February 9, 2022
WebM&M Cases
Hidden Danger!
-
psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - Emergency physicians should be mindful in cases where history-taking is challenging and take appropriate … The heuristics typically applied to cases of head trauma should have caused the clinician to consider … A subsequent analysis showed that the alert was triggered at “clinical time zero” in 41% of cases and … 1, 2006
WebM&M Cases
Hold the tPA
April 1, … 2005
WebM&M Cases
Around the Block
March 1
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psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
January 31, 2024 - for Drug Administration Blur
June 24, 2020
WebM&M Cases … July 1, 2008
WebM&M Cases
Physical Diagnosis … August 1, 2006
WebM&M Cases
Poor Prognosis … Cap
March 1, 2004
WebM&M Cases
Feeling No … Pain
July 1, 2003
WebM&M Cases
Another Fall
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psnet.ahrq.gov/web-mm/nosy-business
March 01, 2007 - In these cases, packing is a reasonable solution. … While many cases of epistaxis are minor, some can be life-threatening emergencies. … Back to Basics
March 1, 2007
WebM&M Cases … Mark My Tooth
August 21, 2007
WebM&M Cases … Techno Trip
March 1, 2005
WebM&M Cases
-
psnet.ahrq.gov/issue/evidence-anchoring-bias-during-physician-decision-making
November 17, 2021 - September 20, 2011
Key use cases for artificial intelligence to reduce the frequency … September 25, 2024
WebM&M Cases
Under Pressure: Delayed … April 24, 2024
WebM&M Cases
Hindsight is 20/20: … Thrombolytics for Alcohol Intoxication
April 10, 2024
WebM&M Cases … April 27, 2022
WebM&M Cases
The NSTEMI Curbside Consultation
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psnet.ahrq.gov/issue/emergency-department-image-interpretation-accuracy-influence-immediate-reporting-radiology
November 09, 2022 - August 17, 2022
WebM&M Cases
Coming up for Err: Missed … a Patient with Recurrent Pneumothorax
August 25, 2021
WebM&M Cases … September 26, 2012
WebM&M Cases
Duty to Disclose Someone … June 23, 2009
WebM&M Cases
X-ray Flip
February 1, … 2004
WebM&M Cases
The Dropped Lung
May 1,
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psnet.ahrq.gov/issue/factors-associated-potentially-missed-diagnosis-appendicitis-emergency-department
December 16, 2020 - August 7, 2024
WebM&M Cases
Bandemia as a Harbinger of … Stercoral Colitis and Impending Perforation
July 31, 2023
WebM&M Cases … March 22, 2014
WebM&M Cases
A Real Heartache
December … 1, 2012
WebM&M Cases
Missed Pneumonia
November … October 20, 2010
WebM&M Cases
Pregnant With Danger
-
psnet.ahrq.gov/issue/diagnostic-challenges-primary-care-identifying-and-avoiding-cognitive-bias
November 03, 2021 - Improving Diagnostic Safety and Quality
April 26, 2023
WebM&M Cases … June 30, 2021
WebM&M Cases
Paroxysmal Supraventricular … Tachycardia Masquerading as Panic Attacks
June 30, 2021
WebM&M Cases … Care: Remembering the Physical Examination
March 31, 2021
WebM&M Cases … December 23, 2020
WebM&M Cases
Endometriosis: A
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psnet.ahrq.gov/web-mm/blind-spot
July 30, 2020 - The Commentary This case illustrates the insidious and surprising nature of many cases of postoperative … In just over half of the ION cases in the ASA POVL Registry, both eyes were affected, consistent with … Spine surgery cases with ION in the ASA POVL Registry are associated with large operative blood loss … Most cases of PION do not progress in the postoperative period if the patient has stable hemodynamics … However, many of these cases are thought to be caused by particulate emboli and thus may not be easily
-
psnet.ahrq.gov/node/865479/psn-pdf
April 03, 2024 - Characteristics and contributing factors of diagnostic
error in surgery: analysis of closed medico-legal cases … Characteristics and contributing factors of diagnostic error in
surgery: analysis of closed medico-legal cases … This study used medico-legal cases and complaints to
characterize surgical diagnostic errors.
-
psnet.ahrq.gov/issue/development-and-psychometric-analysis-patient-reported-measure-diagnostic-excellence
January 10, 2024 - January 10, 2024
WebM&M Cases
Paroxysmal Supraventricular … initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases … October 23, 2019
WebM&M Cases
Hiding in Plain Sight … August 1, 2009
WebM&M Cases
Autopsy Revelation … March 1, 2004
WebM&M Cases
Missed Appendicitis
-
psnet.ahrq.gov/issue/patients-should-know-whos-operating-surgeons-say
May 15, 2024 - June 8, 2022
WebM&M Cases
"Do You Want Everything Done … March 18, 2010
WebM&M Cases
Secured But Not Always Safe … November 1, 2006
WebM&M Cases
DNR in the OR … and Afterwards
September 1, 2006
WebM&M Cases
-
psnet.ahrq.gov/web-mm/hold-tpa
July 29, 2020 - November 15, 2018
WebM&M Cases
The Forgotten Turn … Privacy Gone Awry
May 1, 2004
WebM&M Cases … December 1, 2008
WebM&M Cases
Recurrent Hypoglycemia: … October 1, 2008
WebM&M Cases
One ACE Too Many … July 1, 2006
WebM&M Cases
Lost in Transition
-
psnet.ahrq.gov/node/36993/psn-pdf
September 15, 2011 - A transdisciplinary team acting on evidence through
analyses of moot malpractice cases. … A transdisciplinary team acting on evidence through analyses of moot malpractice cases. … https://psnet.ahrq.gov/issue/transdisciplinary-team-acting-evidence-through-analyses-moot-malpractice-
cases … https://psnet.ahrq.gov/issue/transdisciplinary-team-acting-evidence-through-analyses-moot-malpractice-cases … https://psnet.ahrq.gov/issue/transdisciplinary-team-acting-evidence-through-analyses-moot-malpractice-cases
-
psnet.ahrq.gov/web-mm/confusion-acetaminophen
December 01, 2009 - October 1, 2008
WebM&M Cases
Raise the Bar … April 1, 2006
WebM&M Cases
Lethal Cap … March 1, 2004
WebM&M Cases
Undiagnosed Vaginal … Push
November 1, 2003
WebM&M Cases
Making … June 1, 2003
WebM&M Cases
Missed Appendicitis
-
psnet.ahrq.gov/web-mm/misread-label
August 28, 2024 - The Wrong Shot: Error Disclosure
June 1, 2004
WebM&M Cases … Lethal Cap
March 1, 2004
WebM&M Cases … June 1, 2003
WebM&M Cases
Medication Overdose … April 1, 2003
WebM&M Cases
The 2-Week Itch … April 1, 2003
WebM&M Cases
Unexplained Apnea