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Showing results for "cases".

41. Discrepant advanced directives and code status orders: a preventable medical error. | PSNet
    psnet.ahrq.gov/issue/discrepant-advanced-directives-and-code-status-orders-preventable-medical-error
    October 31, 2018 - Root cause analyses for these cases found that haste, inadequate communication, EMR discrepancies, knowledge … June 10, 2018 WebM&M Cases Poorly Advanced Directives … June 20, 2011 WebM&M Cases Medication Reconciliation … Pitfalls February 1, 2010 WebM&M Cases The … Wrongful Resuscitation April 1, 2008 WebM&M Cases

42. Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017. | PSNet
    psnet.ahrq.gov/issue/outpatient-insulin-related-adverse-events-due-mix-errors-findings-two-national-surveillance
    March 10, 2021 - Most cases of medication mix-up involved rapid-acting insulin. … May 20, 2020 Key use cases for artificial intelligence to reduce the frequency of adverse … December 13, 2023 WebM&M Cases Missed Diagnosis of Addison … March 29, 2023 WebM&M Cases Hospital-Acquired Diabetic … November 4, 2020 WebM&M Cases Inpatient Stroke Management

43. Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care. | PSNet
    psnet.ahrq.gov/issue/prevalence-triggers-and-patient-harm-identified-global-trigger-tool-specialized-palliative
    June 14, 2023 - Of the 26 cases identified by the GTT, 16 were considered part of the patient's disease trajectory or … Improving Diagnostic Safety and Quality April 26, 2023 WebM&M Cases … June 15, 2022 WebM&M Cases Engaging Seriously Ill Older … November 23, 2016 WebM&M Cases SNFs: Opening the Black … October 12, 2012 WebM&M Cases Poor Prognosis September

44. Autopsy interrogation of emergency medicine dispute cases: how often are clinical diagnoses incorrect? | PSNet
    psnet.ahrq.gov/issue/autopsy-interrogation-emergency-medicine-dispute-cases-how-often-are-clinical-diagnoses
    March 24, 2019 - Study Autopsy interrogation of emergency medicine dispute cases: how often are clinical … Autopsy interrogation of emergency medicine dispute cases: how often are clinical diagnoses incorrect … Autopsy interrogation of emergency medicine dispute cases: how often are clinical diagnoses incorrect … July 14, 2018 WebM&M Cases Shortcuts to Acetaminophen-induced … June 25, 2009 WebM&M Cases Delay in Initiating Antibiotics

45. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/854383/psn-pdf
    January 01, 2024 - What can safety cases offer for patient safety? A multisite case study. … What can Safety Cases offer for patient safety? A multisite case study. … https://psnet.ahrq.gov/issue/what-can-safety-cases-offer-patient-safety-multisite-case-study “Safety … cases” are used in healthcare and other industries to communicate the safety of a product, system, … psnet.ahrq.gov/issue/using-safety-cases-industry-and-healthcare https://psnet.ahrq.gov/issue/safety-cases-digital-health-innovations-can-they-work

46. Impact of diagnostic management team on patient time to diagnosis and percent of accurate and clinically actionable diagnoses. | PSNet
    psnet.ahrq.gov/issue/impact-diagnostic-management-team-patient-time-diagnosis-and-percent-accurate-and-clinically
    October 19, 2022 - 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. … September 1, 2021 View More Related Resources WebM&M Cases

47. A systems approach to morbidity and mortality conference. | PSNet
    psnet.ahrq.gov/issue/systems-approach-morbidity-and-mortality-conference
    July 22, 2020 - PSNet offers an online version of such conferences with presentation of cases and expert commentaries … July 22, 2020 Key use cases for artificial intelligence to reduce the frequency of adverse … May 4, 2022 View More Related Resources WebM&M Cases … January 26, 2022 A multidisciplinary model for reviewing severe maternal morbidity cases … Surgical M&M Conference: The M+M Matrix September 1, 2007 WebM&M Cases

48. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867232/psn-pdf
    January 01, 2025 - Role of remediation in cases of serious misconduct before UK healthcare regulators: a qualitative study … Role of remediation in cases of serious misconduct before UK healthcare regulators: a qualitative study … https://psnet.ahrq.gov/issue/role-remediation-cases-serious-misconduct-uk-healthcare-regulators- qualitative-study … study of regulators in the United Kingdom (UK) explored how remediation influences decision-making in cases … https://psnet.ahrq.gov/issue/role-remediation-cases-serious-misconduct-uk-healthcare-regulators-qualitative-study

49. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73866/psn-pdf
    September 22, 2021 - Role of nursing home quality on COVID-19 cases and deaths: evidence from Florida nursing homes. … Role of nursing home quality on COVID-19 cases and deaths: evidence from Florida nursing homes. … https://psnet.ahrq.gov/issue/role-nursing-home-quality-covid-19-cases-and-deaths-evidence-florida- nursing-homes … in Florida, this study explored the association between nursing home characteristics and COVID-19 cases … Findings suggest that the likelihood of COVID-19 cases in nursing homes is related to ownership status

50. Challenges of Diabetes Management and Medication Reconciliation | PSNet
    psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
    March 15, 2023 - When a root-cause-analysis approach is applied to the cases cited above, errors in obtaining accurate … May 16, 2022 WebM&M Cases Wrong Catheter in the … October 1, 2009 WebM&M Cases Blind Spot June … 1, 2005 WebM&M Cases Not a Miscarriage June … September 8, 2021 WebM&M Cases When Looks Aren’t All

51. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/74079/psn-pdf
    December 02, 2020 - Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases: a pragmatic … Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases: a pragmatic … psnet.ahrq.gov/issue/impact-digitally-acquired-peer-diagnostic-input-diagnostic-confidence- outpatient-cases … In cases with high diagnostic uncertainly, peer input increased provider confidence. … psnet.ahrq.gov/issue/impact-digitally-acquired-peer-diagnostic-input-diagnostic-confidence-outpatient-cases

52. Framing of clinical information affects physicians' diagnostic accuracy. | PSNet
    psnet.ahrq.gov/issue/framing-clinical-information-affects-physicians-diagnostic-accuracy
    November 02, 2011 - Using hypothetical patient cases, researchers found that the way in which cases were presented had a … Improving Diagnostic Safety and Quality April 26, 2023 WebM&M Cases … October 10, 2018 WebM&M Cases Tough Call: Addressing … April 4, 2011 WebM&M Cases Defensive Medicine: "Glowing … July 10, 2008 WebM&M Cases The Dropped Lung May 1

53. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60793/psn-pdf
    August 12, 2020 - Is there a link between nursing home reported quality and COVID-19 cases? … Is There a link between nursing home reported quality and COVID-19 cases? … https://psnet.ahrq.gov/issue/there-link-between-nursing-home-reported-quality-and-covid-19-cases- evidence-california … with state-level data to examine the association between nursing home-reported quality and COVID-19 cases … residents, results indicate that nursing homes with higher ratings were less likely to experience COVID-19 cases

54. Comparative accuracy of diagnosis by collective intelligence of multiple physicians vs individual physicians. | PSNet
    psnet.ahrq.gov/issue/comparative-accuracy-diagnosis-collective-intelligence-multiple-physicians-vs-individual
    January 23, 2017 - Physicians can enter cases onto the platform or solve cases that others have entered. … physicians across specialties outperformed individual subspecialists even for subspecialty-relevant cases … Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases … March 27, 2019 Teaching about diagnostic errors through virtual patient cases: a pilot … Exposure to media information about a disease can cause doctors to misdiagnose similar-looking clinical cases

55. Extent of diagnostic agreement among medical referrals. | PSNet
    psnet.ahrq.gov/issue/extent-diagnostic-agreement-among-medical-referrals
    October 31, 2011 - This retrospective medical record review study examined cases where primary care providers sought diagnostic … They found that the diagnosis differed substantially in about one-fifth of cases following the subspecialty … Costs were higher for cases with substantively different diagnoses compared to cases where subspecialists … December 5, 2018 WebM&M Cases Transfusion Thresholds … October 8, 2008 WebM&M Cases Inappropriate Antibiotic

56. Right Electrocardiogram, Wrong Patient | PSNet
    psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
    April 24, 2024 - The Cases Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary … 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 … Systems Changes Needed and Quality Improvement Approach In reviewing the cases, the team sought to … In the majority of the cases, the error was detected by the nurse or clerk prior to EKG transmission

57. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867683/psn-pdf
    March 05, 2025 - Ambulatory medication errors and adverse events involved in medicine-related malpractice cases from … Ambulatory medication errors and adverse events involved in medicine- related malpractice cases from … psnet.ahrq.gov/issue/ambulatory-medication-errors-and-adverse-events-involved-medicine-related- malpractice-cases … psnet.ahrq.gov/issue/ambulatory-medication-errors-and-adverse-events-involved-medicine-related-malpractice-cases … psnet.ahrq.gov/issue/ambulatory-medication-errors-and-adverse-events-involved-medicine-related-malpractice-cases

58. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/47644/psn-pdf
    February 13, 2019 - Using computerized virtual cases to explore diagnostic error in practicing physicians. … Using computerized virtual cases to explore diagnostic error in practicing physicians. … https://psnet.ahrq.gov/issue/using-computerized-virtual-cases-explore-diagnostic-error-practicing- physicians … This simulation study presented virtual patient cases to practicing physicians with the aim of improving … https://psnet.ahrq.gov/issue/using-computerized-virtual-cases-explore-diagnostic-error-practicing-physicians

59. Disclosing harmful medical errors to patients: tackling three tough cases. | PSNet
    psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-tackling-three-tough-cases
    December 19, 2018 - Commentary Disclosing harmful medical errors to patients: tackling three tough cases … Disclosing harmful medical errors to patients: tackling three tough cases. … Disclosing harmful medical errors to patients: tackling three tough cases.

60. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/866731/psn-pdf
    September 18, 2024 - Root cause analysis of cases involving diagnosis. … Root cause analysis of cases involving diagnosis. … https://psnet.ahrq.gov/issue/root-cause-analysis-cases-involving-diagnosis Root cause analysis (RCA) … While the five overarching steps of RCA for cases involving diagnostic error are similar to standard … https://psnet.ahrq.gov/issue/root-cause-analysis-cases-involving-diagnosis https://psnet.ahrq.gov/primer