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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - February 1, 2023
WebM&M Cases
When the Lytes Go … March 29, 2023
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When Taking an SGLT2 … February 16, 2022
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A Sweet Case of Hidden … March 24, 2021
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Multiple Levels Involved … February 26, 2020
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It's Sarah, Not
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psnet.ahrq.gov/issue/safe-patient-outcomes-occur-timely-standardized-communication-critical-values
January 15, 2020 - April 16, 2018
WebM&M Cases
Critical Opportunity Lost … March 23, 2012
WebM&M Cases
Amended Lab Results: Communication … October 7, 2011
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A Seasonal Care Transition
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psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
March 24, 2019 - Approaches to Improving Patient Safety Avoid emergency intubation when possible In cases of pulmonary … December 14, 2022
WebM&M Cases
Is that solution … History Leads to Adverse Outcomes
July 8, 2022
WebM&M Cases … March 29, 2023
WebM&M Cases
Distraction of the … April 26, 2023
WebM&M Cases
The Wrong Blade: A
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - November 16, 2022
WebM&M Cases
Some Patients Can't Wait … Timeliness of Emergency Department Care
March 25, 2020
WebM&M Cases … EMS Perils from Hospital Overcrowding
August 31, 2022
WebM&M Cases … 27, 2023
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WebM&M Cases … July 10, 2024
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Bandemia as a Harbinger of
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psnet.ahrq.gov/issue/missed-injuries-trauma-patients-literature-review
April 01, 2009 - January 11, 2023
WebM&M Cases
Workaround Error
February … September 27, 2017
WebM&M Cases
Emergency Error
August … June 10, 2013
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All in the History
March … 21, 2009
WebM&M Cases
Lethal Vertigo
June … 1, 2004
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Ruptured Heterotopic Pregnancy
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psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
January 29, 2021 - 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 … to Arterial Thrombosis
June 28, 2023
WebM&M Cases … July 10, 2024
WebM&M Cases
Syringe Swap During
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psnet.ahrq.gov/web-mm/liposuction-gone-awry
July 01, 2003 - One recent study used an internet and peer review reporting system to analyze 400,000 cases (since the … report, the database has grown to more than 800,000 cases) performed in roughly 1200 accredited AAAASF … Overrides: A Dangerous Combination
April 24, 2024
WebM&M Cases … December 23, 2020
WebM&M Cases
The One That Got … July 20, 2009
WebM&M Cases
Urinary Retention Dilemma
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psnet.ahrq.gov/web-mm/missing-point-eye-injury
March 01, 2005 - eye-focused history and physical examination, recognize vision-threatening disorders, and identify cases … In cases of trauma, the most serious diagnoses that should be considered and excluded include ruptured … In atraumatic cases, the most common serious diagnoses that should be considered include acute angle … In such cases, the clue may be that the patient was working near high-speed equipment such as a metal … Plain X-ray and computed tomography of the orbit in cases and suspected cases of intraocular foreign
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psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
The Cases
Multiple electrocardiograms … All of the cases involved the nurse or EKG technician either entering the wrong medical
record number … Fortunately, there were no adverse effects on any of the patients involved in the cases of mentioned … The majority of cases came from the emergency department (ED), consistent with previously published … In the majority
of the cases, the error was detected by the nurse or clerk prior to EKG transmission
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psnet.ahrq.gov/issue/death-boy-prompts-new-medical-efforts-nationwide
March 22, 2014 - November 14, 2012
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WebM&M Cases … November 23, 2005
WebM&M Cases
No Blood, Please
May … 1, 2004
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Undiagnosed Vaginal Bleeding … Pregnancy
January 1, 2004
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Ectopic … May 1, 2003
WebM&M Cases
The Dropped Lung
May
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psnet.ahrq.gov/node/42035/psn-pdf
February 13, 2013 - Using Safety Cases in Industry and Healthcare. …
https://psnet.ahrq.gov/issue/using-safety-cases-industry-and-healthcare
This report details … how high-risk industries use safety cases to identify, evaluate, address, and monitor
risks and explains … https://psnet.ahrq.gov/issue/using-safety-cases-industry-and-healthcare
https://psnet.ahrq.gov/issue/
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psnet.ahrq.gov/issue/missed-diagnoses-acute-cardiac-ischemia-emergency-department
November 30, 2012 - February 3, 2011
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WebM&M Cases … March 20, 2024
WebM&M Cases
Paroxysmal Supraventricular … Lead to Dangerous Delay
March 1, 2018
WebM&M Cases … Dissecting the Presentation
April 1, 2015
WebM&M Cases … A Real Heartache
December 1, 2012
WebM&M Cases
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psnet.ahrq.gov/web-mm/outbreak
January 29, 2015 - May 12, 2021
WebM&M Cases
Back to Basics
March 1, … August 26, 2020
WebM&M Cases
Nosy Business … April 1, 2010
WebM&M Cases
Mark My Tooth … Dosing
August 21, 2005
WebM&M Cases
Techno … or Do Not Use the Line
February 1, 2013
WebM&M Cases
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psnet.ahrq.gov/web-mm/not-miscarriage
June 01, 2005 - August 27, 2012
WebM&M Cases
An Outpatient 'Zebra' … January 1, 2006
WebM&M Cases
Who Nose Where the … to Home Parenteral Nutrition Error
May 26, 2021
WebM&M Cases … Insert Omission
April 1, 2006
WebM&M Cases … Do Me a Favor
May 1, 2004
WebM&M Cases
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psnet.ahrq.gov/issue/medication-safety-look-alikesound-alike-drugs-home-care
February 03, 2021 - August 16, 2023
WebM&M Cases
Fatal Patient-Controlled … PCA) Opioid-Induced Respiratory Depression
May 27, 2020
WebM&M Cases … April 17, 2009
WebM&M Cases
Miscalculated Risk
August … 1, 2006
WebM&M Cases
Citrate Mix-Up
May 1,
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psnet.ahrq.gov/issue/error-detection-and-recovery-dialysis-nursing
November 16, 2022 - November 6, 2015
WebM&M Cases
Two Pills, Same Drug … June 1, 2005
WebM&M Cases
Cognitive Overload in … May 27, 2011
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WebM&M Cases … January 18, 2011
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Dangerous Dialysis
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psnet.ahrq.gov/issue/preventable-errors-operating-room-retained-foreign-bodies-after-surgery-part-i
April 28, 2021 - Download Citation
Related Resources From the Same Author(s)
WebM&M Cases … Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough
April … 28, 2021
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Did We Forget Something? … September 1, 2003
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Procedural Mishap
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psnet.ahrq.gov/node/37964/psn-pdf
June 29, 2011 - Impact of miscommunication in medical dispute cases in
Japan. … Impact of miscommunication in medical dispute cases in Japan. … https://psnet.ahrq.gov/issue/impact-miscommunication-medical-dispute-cases-japan
This study of closed … https://psnet.ahrq.gov/issue/impact-miscommunication-medical-dispute-cases-japan
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psnet.ahrq.gov/node/38987/psn-pdf
May 04, 2014 - Disclosing harmful medical errors to patients: tackling
three tough cases. … Disclosing harmful medical errors to patients: tackling three tough
cases. … https://psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-tackling-three-tough-cases
This … https://psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-tackling-three-tough-cases
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psnet.ahrq.gov/web-mm/autopsy-revelation
December 01, 2007 - that advances in medical technology have rendered the autopsy unnecessary in all but extraordinary cases … , but possibly as many as 7.9% of cases depending on the percentage of decedents undergoing autopsy. … December 1, 2007
WebM&M Cases
Patient Mix-Up … No Blood, Please
May 1, 2004
WebM&M Cases … X-ray Flip
February 1, 2004
WebM&M Cases