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psnet.ahrq.gov/node/43818/psn-pdf
January 21, 2015 - examined the characteristics of medical negligence claims in otolaryngology (ear, nose, and
throat) cases … Researchers reviewed 65 closed cases that resulted in payouts and
found that surgical complications … were implicated in 50 of the cases.
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psnet.ahrq.gov/web-mm/dual-therapy-debacle
February 01, 2007 - June 16, 2019
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What Happened on Telemetry … April 1, 2019
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Baffled by Botulinum … Records
November 1, 2010
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Bad … Writing, Wrong Medication
April 1, 2010
WebM&M Cases … Crossed Coverage
February 1, 2007
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psnet.ahrq.gov/web-mm/resuscitate-or-not
November 01, 2011 - .′( 2 ) In some cases, our reactions to our errors may alter usual clinical decision-making. … June 21, 2016
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October 1, 2003
WebM&M Cases … Check the Bags
September 1, 2003
WebM&M Cases … July 1, 2003
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Not a Miscarriage
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psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - August 1, 2009
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DRESSed for Failure … September 30, 2020
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Life-Threatening Infant … Overdose of Sodium Chloride
May 27, 2020
WebM&M Cases … Epilogue
April 1, 2009
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Sick and … Dapsone
June 1, 2004
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Too Tight
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psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
March 30, 2016 - March 30, 2016
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Are You Mrs. A? … Issue of Identification Over Telephone
October 1, 2013
WebM&M Cases … Pseudo-obstruction But a Real Perforation
July 1, 2017
WebM&M Cases … December 23, 2016
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Nonsustained Ventricular … Citrate Mix-Up
May 1, 2006
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psnet.ahrq.gov/web-mm/rapid-mis-strep
February 01, 2004 - Fasciitis
August 21, 2014
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A Real … January 14, 2011
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Pregnant With Danger … May 1, 2005
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The Worst Headache … July 1, 2004
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Crushing Chest Pain: … A Missed Opportunity
January 1, 2004
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psnet.ahrq.gov/web-mm/weak-response
February 24, 2011 - Yet in some cases, vital signs are available to us, if we look for them. … August 1, 2006
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Undiagnosed Vaginal … a Tough Position
October 1, 2003
WebM&M Cases … Missed Appendicitis
June 1, 2003
WebM&M Cases … Suicidal Man With Gun
May 1, 2003
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psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
February 01, 2004 - Cases where there are simple lapses in the system are heart wrenching because the errors are so clear … Prior malpractice cases do not provide specific guidance, applicable to all circumstances, regarding … However, a general, common-sense principle can be deduced from review of a number of such cases, plus … related cases involving patients who do not appear for an important scheduled follow-up appointment … I am unaware of any malpractice cases that have addressed the Internet specifically, but future juries
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psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
March 01, 2005 - 11 emergency departments (EDs) throughout the US in August 2004, MRSA was identified in 59% of the cases … The IDSA guidelines recommend use of adjunctive antibiotic therapy after incision and drainage in cases … Preventable Rash
March 1, 2005
WebM&M Cases … October 27, 2021
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Pre-analytical pitfalls … Another
February 1, 2011
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The
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psnet.ahrq.gov/web-mm/missing-trauma
March 03, 2011 - These cases often lead to full trauma alerts, accompanied by many mobilized resources, followed by total … March 10, 2019
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January 1, 2004
WebM&M Cases … Missed Appendicitis
June 1, 2003
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May
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psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
September 20, 2011 - In such cases, ongoing efforts to record an objective and complete neurologic examination need to be … July 28, 2010
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Back to Basics
March 1 … , 2007
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Reaction to Dye
September … December 1, 2006
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Inadvertent … Man With Gun
May 1, 2003
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The
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psnet.ahrq.gov/web-mm/check-anesthesia-machine
August 01, 2006 - update on patient injuries from anesthesia delivery equipment that resulted in settled malpractice cases … October 19, 2022
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Late Anemia Following Rh … The Forgotten Line
May 1, 2012
WebM&M Cases … 1, 2004
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Did We Forget Something? … September 1, 2003
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Unexplained Apnea
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psnet.ahrq.gov/web-mm/allergy-holter
May 01, 2008 - September 28, 2022
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Milliliters vs. … Considerations
December 1, 2004
WebM&M Cases … Carpe Diem (Seize the Day)
December 1, 2004
WebM&M Cases … Transfusion "Slip"
February 1, 2004
WebM&M Cases … Patient Mix-Up
February 1, 2003
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psnet.ahrq.gov/web-mm/mistaken-identity
December 18, 2014 - In some cases, incorrect identification may lead primarily to provider embarrassment without any patient … In cases when a patient wristband is removed (e.g., for surgery or IV placement) or has fallen off (e.g … July 1, 2011
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Say It Again
June … 1, 2011
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The ECG Is Not Normal … June 1, 2011
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Treatment Challenges
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psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
February 01, 2014 - December 13, 2017
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Failure to Reevaluate … February 14, 2017
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Bowel Prep
July 1, … of Medical Overuse
March 1, 2017
WebM&M Cases … All in the History
March 21, 2009
WebM&M Cases … May 1, 2007
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Fumbled Handoff
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psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
February 01, 2019 - Nearly all cases (97%) were judged to be either likely or certainly preventable 8 through the use of … November 13, 2024
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Hemorrhagic Shock after … July 10, 2024
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“Copy and Paste” Notes … March 8, 2023
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Open wider: Failure to use … November 24, 2021
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To Dilute or Not Dilute
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psnet.ahrq.gov/web-mm/turn-other-cheek
October 26, 2010 - by Text: Multitasking Mishap
December 1, 2011
WebM&M Cases … Pocket Syringe Swap
May 1, 2011
WebM&M Cases … March 29, 2023
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Delayed Diagnosis and … January 16, 2010
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Right? Left? … May 1, 2006
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Inadvertent Castration
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psnet.ahrq.gov/issue/profiles-patient-safety-medication-errors-emergency-department
February 03, 2010 - September 12, 2011
Root cause analysis of cases involving diagnosis. … December 1, 2008
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Lost in Transition … February 1, 2006
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Pregnant With Danger … May 1, 2005
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Hold the tPA
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psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
January 07, 2015 - artery (PA) catheter insertion and monitoring was very common during anesthesia for cardiac surgical cases … Take-Home Points Pulmonary artery catheters may still be used in cardiac surgery cases, but they … June 23, 2015
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Good Catch in the Operating … 1, 2012
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Order Interrupted by Text … : Multitasking Mishap
December 1, 2011
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psnet.ahrq.gov/web-mm/dont-pick-picc
December 01, 2011 - Nephrology consultation may be useful in cases in which there is ambiguity about the risk of needing … December 1, 2011
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Some Patients Can't … March 1, 2019
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Primary Workaround, … Secondary Complication
July 1, 2018
WebM&M Cases … PCA Overdose
August 21, 2005
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