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  1. 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?
  2. 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
  3. 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
  4. Psn-Pdf (pdf file)

    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
  5. 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!
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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,
  11. 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
  12. 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
  13. 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
  14. Psn-Pdf (pdf file)

    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.
  15. 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
  16. 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
  17. 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
  18. Psn-Pdf (pdf file)

    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
  19. 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
  20. 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

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