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  1. Late Anemia Following Rh Disease in a Newborn | PSNet

    psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
    June 17, 2010 - The third step is judicious treatment with phototherapy (or, in rare cases, exchange transfusion) when … Hemolysis Holdup May 1, 2017 WebM&M Cases … Pathologic Mistake March 1, 2013 WebM&M Cases … 1, 2007 WebM&M Cases Pregnant With Danger … May 1, 2005 WebM&M Cases No Blood, Please May

  2. Preventable Rash | PSNet

    psnet.ahrq.gov/web-mm/preventable-rash
    October 01, 2012 - It is estimated that STD cases reported to CDC represent only 50%-80% of reportable STD infections in … Not a Miscarriage June 1, 2003 WebM&M Cases … Missed Appendicitis June 1, 2003 WebM&M Cases … The Dropped Lung May 1, 2003 WebM&M Cases … Suicidal Man With Gun May 1, 2003 WebM&M Cases

  3. Wrong Turn through Colon: Misplaced PEG | PSNet

    psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
    May 01, 2017 - In a review of 28 such cases, 16 occurred after PEG replacement; thus, it is important to follow standard … Misplacement of percutaneously inserted gastrostomy tube into the colon: report of 6 cases and review … to Sepsis October 1, 2016 WebM&M Cases The … December 1, 2012 WebM&M Cases Peripheral IV in … (Un)Awareness September 1, 2011 WebM&M Cases

  4. Patient Identification Errors: A Systems Challenge | PSNet

    psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
    February 23, 2011 - The Cases The following four events involving five patients all involved incorrect patient identification … in a large tertiary care hospital; all cases were reported to the hospital’s patient safety committee … Together, these cases serve to highlight several important systems issues. … October 13, 2018 WebM&M Cases An Inadvertent Bolus of … August 3, 2022 WebM&M Cases CA-MRSA Skin Infections:

  5. Urinary Retention Dilemma | PSNet

    psnet.ahrq.gov/web-mm/urinary-retention-dilemma
    March 01, 2013 - March 1, 2007 WebM&M Cases Polypharmacy … , Multifarious Errors April 1, 2013 WebM&M Cases … of Prevention January 1, 2006 WebM&M Cases … PCA Overdose August 21, 2005 WebM&M Cases … Discharge Against Medical Advice May 1, 2005 WebM&M Cases

  6. Hold That Order | PSNet

    psnet.ahrq.gov/web-mm/hold-order
    December 19, 2018 - Health Records April 1, 2017 WebM&M Cases … May 29, 2024 WebM&M Cases An Inadvertent Bolus … to Home Parenteral Nutrition Error May 26, 2021 WebM&M Cases … 28, 2021 WebM&M Cases A Postpartum Woman with … October 28, 2020 WebM&M Cases When Looks Aren’t

  7. Unexpected Drawbacks of Electronic Order Sets | PSNet

    psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
    December 01, 2017 - October 13, 2018 WebM&M Cases PCA Overdose August … 21, 2005 WebM&M Cases Privacy or Safety? … August 21, 2015 WebM&M Cases Good Catch in the … the Other Cheek March 1, 2012 WebM&M Cases … Leads to Sepsis October 1, 2016 WebM&M Cases

  8. "Superficial" Report Leads to "Deep" Problem | PSNet

    psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
    July 01, 2012 - May 1, 2011 WebM&M Cases Paradoxical Pulse … February 1, 2011 WebM&M Cases Reconciling Records … : Held Too Long April 1, 2010 WebM&M Cases … Eptifibatide Epilogue April 1, 2009 WebM&M Cases … Transfusion "Slip" February 1, 2004 WebM&M Cases

  9. Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics. | PSNet

    psnet.ahrq.gov/issue/missed-diagnoses-acute-myocardial-infarction-emergency-department-variation-patient-and
    April 08, 2018 - initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases … May 3, 2023 View More Related Resources WebM&M Cases … April 8, 2018 WebM&M Cases Missing ECG and Missed Diagnosis … June 24, 2015 WebM&M Cases Dissecting the Presentation … October 15, 2014 WebM&M Cases A Real Heartache December

  10. Transfusion Thresholds in Gastrointestinal Bleeding | PSNet

    psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
    November 26, 2014 - The presence of blood clots in the stool decreases the likelihood of upper GIB.( 9 ) However, in some cases … created to alert physicians to clinical situations to which these templates may not apply, including cases … November 26, 2014 WebM&M Cases Chemotherapy Extravasation … Language Barrier April 1, 2006 WebM&M Cases … Lethal Vertigo June 1, 2004 WebM&M Cases

  11. The Worst Headache | PSNet

    psnet.ahrq.gov/web-mm/worst-headache
    July 01, 2016 - April 8, 2018 WebM&M Cases Neurological Red Flags: A … Critical Opportunity Lost March 1, 2015 WebM&M Cases … July 8, 2022 WebM&M Cases Dangers of Missing an … Pregnant With Danger May 1, 2005 WebM&M Cases … Lethal Vertigo June 1, 2004 WebM&M Cases

  12. Implicit bias in stroke care: a recurring old problem in the rising incidence of young stroke. | PSNet

    psnet.ahrq.gov/issue/implicit-bias-stroke-care-recurring-old-problem-rising-incidence-young-stroke
    June 08, 2010 - January 23, 2013 View More Related Resources WebM&M Cases … May 29, 2024 WebM&M Cases Under Pressure: Delayed … June 3, 2010 WebM&M Cases Lost in Transition February … 1, 2006 WebM&M Cases Deciphering the Code … February 1, 2006 WebM&M Cases Crushing Chest Pain

  13. The nature and causes of unintended events reported at ten emergency departments. | PSNet

    psnet.ahrq.gov/issue/nature-and-causes-unintended-events-reported-ten-emergency-departments
    February 20, 2013 - Critical Radiology Alert Process October 30, 2024 WebM&M Cases … June 1, 2010 WebM&M Cases Medication Reconciliation … Pitfalls February 1, 2010 WebM&M Cases Do … October 1, 2007 WebM&M Cases Caution, Interrupted … September 1, 2004 WebM&M Cases Delay in Initiating

  14. Empiric Steroids: the Good, the Bad, and the Ugly | PSNet

    psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
    June 01, 2015 - The principal message for this and other cases is that glucocorticoids (don't use the term "corticosteroids … February 1, 2010 WebM&M Cases All in the History … March 21, 2009 WebM&M Cases Dangerous Shift … November 1, 2008 WebM&M Cases Where's the … of the Matter June 1, 2005 WebM&M Cases A

  15. Pseudo-obstruction But a Real Perforation | PSNet

    psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
    April 01, 2015 - March 9, 2016 WebM&M Cases Chemotherapy Administration … Safety Standards September 1, 2018 WebM&M Cases … March 29, 2023 WebM&M Cases Respiratory Distress … after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. … February 1, 2023 WebM&M Cases Delayed Diagnosis

  16. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? | PSNet

    psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
    March 01, 2004 - Hospitals need safety indicators that identify cases that will prove on investigation to involve true … Another concern is that culprit quality problems in cases such as the present one may be undetectable … A methodology for targeting hospital cases for quality of care record reviews. … November 28, 2012 WebM&M Cases Comanagement: Who's in … July 1, 2008 WebM&M Cases Do Not Disturb!

  17. Errors in Sepsis Management | PSNet

    psnet.ahrq.gov/web-mm/errors-sepsis-management
    November 03, 2015 - before the initiation of antibiotics), treating with appropriate broad-spectrum antibiotics, and in cases … November 3, 2015 WebM&M Cases Premature Closure: Was … November 25, 2020 WebM&M Cases The Inside of a … Time Out May 1, 2008 WebM&M Cases One ACE Too … To LP or Not LP October 1, 2003 WebM&M Cases

  18. A "Reflexive" Diagnosis in Primary Care | PSNet

    psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
    April 01, 2008 - not present in 81.1% of index visits and that practitioners copied and pasted prior notes in 7.4% of cases … Tables Related Resources From the Same Author(s) WebM&M Cases … The Forgotten Drip April 1, 2008 WebM&M Cases … EMS Perils from Hospital Overcrowding August 31, 2022 WebM&M Cases … The Worst Headache July 1, 2004 WebM&M Cases

  19. Transfer Troubles | PSNet

    psnet.ahrq.gov/web-mm/transfer-troubles
    December 29, 2014 - In other reported cases, documentation has been illegible or contained inadequate or incomplete patient … August 1, 2009 WebM&M Cases To Transfer or Not … December 1, 2006 WebM&M Cases A Stroke of … Heterotopic Pregnancy January 1, 2004 WebM&M Cases … Making Do September 1, 2003 WebM&M Cases

  20. The Wet Read | PSNet

    psnet.ahrq.gov/web-mm/wet-read
    October 01, 2017 - rate of major discrepancies that may alter patient care ranges from less than 1% to around 2.3% of cases … It would, however, be very difficult to provide this level of review for all cases because home access … These cases must be reviewed early enough in the day to provide the referring physicians comfort that … 1, 2007 WebM&M Cases Right? … September 1, 2004 WebM&M Cases The Dropped
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