-
psnet.ahrq.gov/node/38046/psn-pdf
September 10, 2008 - pathological disagreement upon the cause of
death in a teaching hospital: analysis of 100 autopsy
cases … pathological disagreement upon the cause of death
in a teaching hospital: Analysis of 100 autopsy cases … clinical-and-pathological-disagreement-upon-cause-death-teaching-hospital-
analysis-100
This study discovered that autopsy-detected diagnostic errors occurred in 10% of cases
-
psnet.ahrq.gov/node/45640/psn-pdf
September 01, 2018 - Investigators analyzed 125 adverse event cases from 5 New York City hospitals over a 22-month period … The majority of cases did not
involve substandard care, and disclosure occurred in more than 90% of … cases.
-
psnet.ahrq.gov/web-mm/situational-unawareness
August 01, 2009 - August 1, 2009
WebM&M Cases
DRESSed for Failure … as a Tool for Improving Patient Safety
March 29, 2023
WebM&M Cases … Treatment Challenges After Discharge
November 1, 2010
WebM&M Cases … Too Tight Control
May 1, 2004
WebM&M Cases … The 2-Week Itch
April 1, 2003
WebM&M Cases
-
psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - In many cases, the admitting hospitalist may not have an opportunity to speak to the PCP directly and … December 21, 2014
WebM&M Cases
Allergy to Holter … Empty Handoff
September 1, 2012
WebM&M Cases … October 1, 2011
WebM&M Cases
To Transfer or Not … Elopement
December 1, 2007
WebM&M Cases
-
psnet.ahrq.gov/web-mm/toxic-tachycardia
March 01, 2005 - Table
Related Resources From the Same Author(s)
WebM&M Cases … a Patient with Recurrent Pneumothorax
August 25, 2021
WebM&M Cases … November 25, 2020
WebM&M Cases
Think Like a Surgeon … An Obstructed View
October 1, 2015
WebM&M Cases … A "Reflexive" Diagnosis in Primary Care
April 1, 2014
WebM&M Cases
-
psnet.ahrq.gov/web-mm/misleading-complaint
December 01, 2009 - The Commentary Diagnostic errors are estimated to occur in up to 15% of cases ( 1 ) and are an important … May 1, 2011
WebM&M Cases
Antiseizure Medication … Disorder
May 1, 2007
WebM&M Cases
Back to … Basics
March 1, 2007
WebM&M Cases
The Worst … June 1, 2003
WebM&M Cases
Ectopic or Not?
-
psnet.ahrq.gov/web-mm/one-ace-too-many
June 21, 2016 - April 18, 2016
WebM&M Cases
Premature Closure: Was It … June 16, 2019
WebM&M Cases
Dropping the Ball Despite … October 1, 2008
WebM&M Cases
Right? Left? … May 1, 2006
WebM&M Cases
Lost in Transition … June 1, 2003
WebM&M Cases
The Dropped Lung
-
psnet.ahrq.gov/web-mm/little-shuteye
December 22, 2018 - May 20, 2020
WebM&M Cases
Add-on Case and the Missing … Lethal Vertigo
June 1, 2004
WebM&M Cases … X-ray Flip
February 1, 2004
WebM&M Cases … To LP or Not LP
October 1, 2003
WebM&M Cases … June 1, 2003
WebM&M Cases
Missed Appendicitis
-
psnet.ahrq.gov/node/35405/psn-pdf
December 14, 2007 - Compiling data for more than 1000 Medicare
beneficiaries from acute-care hospitals, investigators captured cases … authors report that
potential quality problems were identified at much higher rates in the flagged cases … subjectivity in physician case review exists, this study offers a potential strategy for
selecting cases
-
psnet.ahrq.gov/node/34863/psn-pdf
June 12, 2007 - internal-bleeding-truth-behind-americas-terrifying-epidemic-medical-mistakes-
updated-edition
Wachter and Shojania adapted many of the cases … they previously published in the academic literature,
some cases previously described in the lay literature … the Duke transplant mix-up and the death of
Betsy Lehman at Dana-Farber Cancer Institute), and other cases
-
psnet.ahrq.gov/web-mm/bleeding-risk
November 01, 2003 - July 19, 2010
WebM&M Cases
Allergy to Holter
July … 1, 2004
WebM&M Cases
Is It Safe to Be Direct? … February 1, 2018
WebM&M Cases
Crushing Chest … June 16, 2019
WebM&M Cases
One ACE Too Many
July … April 1, 2003
WebM&M Cases
Unexplained Apnea
-
psnet.ahrq.gov/web-mm/sloppy-and-paste
February 02, 2011 - February 2, 2011
WebM&M Cases
Missing ECG and Missed … November 13, 2024
WebM&M Cases
Low on the Totem Pole … March 6, 2013
WebM&M Cases
A Painful Dilemma
June … 1, 2012
WebM&M Cases
Failure to Reevaluate … December 1, 2010
WebM&M Cases
Discharge Fumbles
-
psnet.ahrq.gov/web-mm/air-side-caution
April 21, 2015 - Cases are usually booked with little room for delay and staff may have work-hour restrictions that put … July 13, 2010
WebM&M Cases
Communication Failure—Who's … May 16, 2022
WebM&M Cases
The Hidden Danger of … Unseen Intravenous Catheters
October 27, 2021
WebM&M Cases … The Forgotten Line
May 1, 2012
WebM&M Cases
-
psnet.ahrq.gov/web-mm/easily-forgotten-tube
June 01, 2016 - The Duke Experience
May 1, 2005
WebM&M Cases … Eptifibatide Epilogue
April 1, 2009
WebM&M Cases … April 13, 2022
WebM&M Cases
Primary Workaround, Secondary … Complication
July 1, 2018
WebM&M Cases
Total … Wrong Turn through Colon: Misplaced PEG
August 1, 2012
WebM&M Cases
-
psnet.ahrq.gov/web-mm/amphotericin-toxicity
April 01, 2014 - June 14, 2017
WebM&M Cases
One Toxic Drug Is Not Like … August 28, 2019
WebM&M Cases
Unexpected Drawbacks of … March 4, 2011
WebM&M Cases
Eptifibatide Epilogue … November 1, 2008
WebM&M Cases
Citrate Mix-Up … May 1, 2006
WebM&M Cases
XL or Smaller?
-
psnet.ahrq.gov/web-mm/lethal-vertigo
September 20, 2011 - December 21, 2014
WebM&M Cases
Staggered Sensitivity … Results
March 1, 2007
WebM&M Cases
Urinary … Retention Dilemma
November 1, 2006
WebM&M Cases … Polypharmacy
May 1, 2013
WebM&M Cases … X-ray Flip
February 1, 2004
WebM&M Cases
-
psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-large-population-based
April 08, 2018 - initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases … March 1, 2023
WebM&M Cases
Missing a Large Vessel Occlusion … August 4, 2015
WebM&M Cases
Misleading Complaint … July 1, 2012
WebM&M Cases
Duty to Disclose Someone … May 1, 2011
WebM&M Cases
The Worst Headache
-
psnet.ahrq.gov/web-mm/missed-pneumonia
June 01, 2005 - April 10, 2024
WebM&M Cases
Hiding in Plain Sight … Pregnant With Danger
May 1, 2005
WebM&M Cases … The Worst Headache
July 1, 2004
WebM&M Cases … Missed TB
May 1, 2004
WebM&M Cases … X-ray Flip
February 1, 2004
WebM&M Cases
-
psnet.ahrq.gov/web-mm/poor-prognosis
March 15, 2016 - March 15, 2016
WebM&M Cases
Looking for Meds in All the … Wrong Places
October 1, 2012
WebM&M Cases … On the Other Hand
May 1, 2007
WebM&M Cases … A Troubling Amine
September 1, 2006
WebM&M Cases … December 2, 2009
WebM&M Cases
Right? Left?
-
psnet.ahrq.gov/web-mm/poorly-advanced-directives
August 01, 2018 - Transport
February 1, 2019
WebM&M Cases
The … December 1, 2011
WebM&M Cases
Watch the Warfarin … July 1, 2011
WebM&M Cases
Recurrent Hypoglycemia … April 1, 2008
WebM&M Cases
Deciphering the … Code
February 1, 2006
WebM&M Cases
No Blood