-
psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
January 29, 2021 - History Leads to Adverse Outcomes
July 8, 2022
WebM&M Cases … March 29, 2023
WebM&M Cases
Open wider: Failure … to Arterial Thrombosis
June 28, 2023
WebM&M Cases … March 15, 2023
WebM&M Cases
Open wider: Failure … July 28, 2021
WebM&M Cases
Fumbled Handoff
-
psnet.ahrq.gov/node/865967/psn-pdf
May 29, 2024 - Diagnostic management teams (DMT), which are comprised of experts in specialized fields, review patient
cases … Cases
reviewed by the DMT were twice as likely to have a diagnostic conclusion (i.e., ruled in or ruled … out
coagulopathy) than cases without DMT.
-
psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
May 27, 2020 - September 23, 2020
WebM&M Cases
Getting the Diagnosis … Both Right and Wrong
September 25, 2019
WebM&M Cases … June 16, 2019
WebM&M Cases
Unintended Consequences of … CPOE
October 1, 2016
WebM&M Cases
Sick and … Pregnant
November 1, 2008
WebM&M Cases
Two
-
psnet.ahrq.gov/web-mm/raise-bar
May 29, 2024 - A new approach to preanesthetic site verification after 2 cases of wrong site peripheral nerve blocks … January 26, 2022
WebM&M Cases
To Dilute or Not Dilute … Pocket Syringe Swap
May 1, 2011
WebM&M Cases … 1, 2004
WebM&M Cases
Listen to the Family … June 1, 2004
WebM&M Cases
Too Tight Control
-
psnet.ahrq.gov/node/36868/psn-pdf
August 29, 2011 - Quali-quantitative analysis: a new model for evaluation of
unusual cases in hospital performance? … Quali-quantitative analysis: a new model for evaluation of unusual cases in hospital performance? … https://psnet.ahrq.gov/issue/quali-quantitative-analysis-new-model-evaluation-unusual-cases-hospital- … https://psnet.ahrq.gov/issue/quali-quantitative-analysis-new-model-evaluation-unusual-cases-hospital-performance … https://psnet.ahrq.gov/issue/quali-quantitative-analysis-new-model-evaluation-unusual-cases-hospital-performance
-
psnet.ahrq.gov/web-mm/ectopic-or-not
March 27, 2024 - November 25, 2020
WebM&M Cases
Misdiagnosis of … Insert Omission
April 1, 2006
WebM&M Cases … Poor Prognosis
September 1, 2004
WebM&M Cases … The Other Side
October 1, 2003
WebM&M Cases … Not a Miscarriage
June 1, 2003
WebM&M Cases
-
psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
January 29, 2021 - A closed claims analysis reported 61 cases of awareness during general anesthesia; only 9 of these cases … World J Clin Cases . 2020;8(2):245-254. [ Free full text ] Chung HS. … History Leads to Adverse Outcomes
July 8, 2022
WebM&M Cases … March 29, 2023
WebM&M Cases
Distraction of the … March 15, 2023
WebM&M Cases
Open wider: Failure
-
psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - The Missing Bedside Examination When doctors recall cases in which they missed a diagnosis, they frequently … retrospective study in Japan found that delayed diagnosis occurred in 31% of their perforated bowel cases … May 16, 2022
WebM&M Cases
Challenges of Diabetes … Echocardiogram Result Lost to Follow-up
June 14, 2023
WebM&M Cases … When the Meds Don’t Reach the Bed
August 26, 2020
WebM&M Cases
-
psnet.ahrq.gov/web-mm/round-trip-service
April 26, 2023 - September 12, 2016
WebM&M Cases
Infused, Not Ingested … 1, 2003
WebM&M Cases
Slow Down: Right Drug, Wrong … of Error
May 1, 2006
WebM&M Cases
Root Cause … May 8, 2013
WebM&M Cases
Tacit Handover, Overt Mishap … Do
September 1, 2003
WebM&M Cases
Suicidal
-
psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - November 21, 2021
WebM&M Cases
Turn the Other Cheek … February 10, 2021
WebM&M Cases
Hip Fractures in Older … November 5, 2014
WebM&M Cases
Discontinued Medications … May 1, 2014
WebM&M Cases
Discharge Instructions … June 1, 2012
WebM&M Cases
Patient Safety and
-
psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - Most cases are associated with hemostatic abnormalities, either patient-related or iatrogenic.( 8 ) In … Although cases also have been reported with unfractionated heparin, the complication is much less common … September 1, 2006
WebM&M Cases
Right? … May 1, 2006
WebM&M Cases
On O.R. Off? … 1, 2004
WebM&M Cases
Too Tight Control
May
-
psnet.ahrq.gov/node/36701/psn-pdf
January 18, 2011 - Error and patient safety: ethical analysis of cases in
occupational and physical therapy practice. … Error and patient safety: ethical analysis of cases in occupational and
physical therapy practice. … https://psnet.ahrq.gov/issue/error-and-patient-safety-ethical-analysis-cases-occupational-and-physical … https://psnet.ahrq.gov/issue/error-and-patient-safety-ethical-analysis-cases-occupational-and-physical-therapy-practice … https://psnet.ahrq.gov/issue/error-and-patient-safety-ethical-analysis-cases-occupational-and-physical-therapy-practice
-
psnet.ahrq.gov/issue/noahs-story-please-listen
June 27, 2018 - July 29, 2009
View More
Related Resources
WebM&M Cases … January 18, 2023
WebM&M Cases
Open wider: Failure to … November 4, 2015
WebM&M Cases
Residual Anesthesia: Tepid … Burn
August 1, 2012
WebM&M Cases
Routine Goes … April 1, 2006
WebM&M Cases
Privacy Gone Awry
-
psnet.ahrq.gov/web-mm/silent-pain-neck
August 19, 2020 - It is important to emphasize that cases of delayed hemorrhage, occurring 24 hours or more after thyroid … In cases of airway obstruction secondary to hematoma, immediate intubation should be performed by an … March 29, 2023
WebM&M Cases
Respiratory Distress … after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. … December 15, 2011
WebM&M Cases
The Forgotten Turn
-
psnet.ahrq.gov/web-mm/more-treatment-better-care
August 11, 2021 - While there is no cure, most cases recover with time on their own. … August 11, 2021
WebM&M Cases
Don't Pick the PICC … December 1, 2012
WebM&M Cases
Peripheral IV in … of Cross Coverage
May 1, 2012
WebM&M Cases … Poorly Advanced Directives
February 1, 2012
WebM&M Cases
-
psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
February 23, 2022 - specific. 6 Positioning of the CVC was in agreement between ultrasound and chest x-ray in 98.9% of cases … In the largest published series of 236 cases of CVC guidewire retention from England’s “Never Event” … unstable patients. distraction and operator skill as major reasons for this complication. 12 In all cases … operation, or information about another sick patient. 13 In the great majority of these and other cases … March 17, 2021
WebM&M Cases
Benefits vs.
-
psnet.ahrq.gov/node/60241/psn-pdf
February 24, 2022 - number of weekly cases and
deaths to date in the pandemic, rising to 5,333 confirmed cases and 565 deaths … There was an even greater increase in staff cases,
from 495 confirmed cases and 5 deaths at the lowest … State Reporting of Cases and Deaths Due to COVID-19 in Long-Term Care
Facilities. … Is there a link between nursing home reported quality and COVID-19 cases? … Nursing Home Resident and Staff Covid-19 Cases After the First
Vaccination Clinic.
-
psnet.ahrq.gov/web-mm/double-dose-transfer
November 01, 2012 - 1, 2004
WebM&M Cases
Abdominal Aortic Aneurysm … in Plain Sight
August 1, 2009
WebM&M Cases … December 1, 2014
WebM&M Cases
Missed Pneumonia … June 1, 2012
WebM&M Cases
Treatment Challenges … After Discharge
November 1, 2010
WebM&M Cases
-
psnet.ahrq.gov/issue/retrospective-analysis-demonstrates-failure-document-key-comorbid-diseases-anesthesia
May 26, 2021 - Download Citation
Related Resources From the Same Author(s)
WebM&M Cases … September 22, 2021
WebM&M Cases
Endometriosis: A Common … and Commonly Missed and Delayed Diagnosis
June 24, 2020
WebM&M Cases … August 12, 2020
WebM&M Cases
Multiple Missed Opportunities … March 10, 2011
WebM&M Cases
Around the Block
March
-
psnet.ahrq.gov/issue/commercialised-experience-operating-embodied-preferences-ambiguous-variations-and-explaining
August 24, 2022 - August 31, 2022
WebM&M Cases
Nothing Called Small Surgery … April 4, 2011
WebM&M Cases
Impatient Inpatient Dosing … August 21, 2005
WebM&M Cases
Lap Burn … October 1, 2004
WebM&M Cases
Ectopic or Not? … May 1, 2003
WebM&M Cases
Procedural Mishap: Learning