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21. Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases and complaints in Canada. | PSNet
    psnet.ahrq.gov/issue/characteristics-and-contributing-factors-diagnostic-error-surgery-analysis-closed-medico
    April 16, 2019 - Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases … Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases … This study used medico-legal cases and complaints to characterize surgical diagnostic errors. … December 14, 2022 WebM&M Cases Open wider: Failure to … October 27, 2022 WebM&M Cases Delayed Diagnosis

22. The business case for quality: case studies and an analysis. | PSNet
    psnet.ahrq.gov/issue/business-case-quality-case-studies-and-analysis
    February 23, 2019 - The cases include management of high-cost pharmaceuticals, diabetes management, smoking cessation, and

23. How common are cognitive errors in cases presented at emergency medicine resident morbidity and mortality conferences? | PSNet
    psnet.ahrq.gov/issue/how-common-are-cognitive-errors-cases-presented-emergency-medicine-resident-morbidity-and
    May 08, 2019 - Study How common are cognitive errors in cases presented at emergency medicine resident … How common are cognitive errors in cases presented at emergency medicine resident morbidity and mortality … This retrospective review of cases presented at one hospital's emergency medicine morbidity and mortality … How common are cognitive errors in cases presented at emergency medicine resident morbidity and mortality … September 12, 2011 WebM&M Cases Multiple Missed Opportunities

24. Final Progress Report: Diagnostic Error in Dystonia (pdf file)
    www.ahrq.gov/sites/default/files/2025-03/tanner-report.pdf
    January 01, 2025 - In 625 cases of primary dystonia and 6250 controls, utilization data show that cases had more medical … Of these cases, 520 incident dystonia cases were contacted regarding the diagnostic error survey; 218 … cases completed the survey. … Thirty-two (70%) cervical dystonia cases, 25 (66%) blepharospasm cases, 31 (61%) laryngeal dystonia … blepharospasm cases, and 41% (14/34) of limb dystonia cases.

25. Impact of miscommunication in medical dispute cases in Japan. | PSNet
    psnet.ahrq.gov/issue/impact-miscommunication-medical-dispute-cases-japan
    September 25, 2019 - Study Impact of miscommunication in medical dispute cases in Japan. … Impact of miscommunication in medical dispute cases in Japan. … Impact of miscommunication in medical dispute cases in Japan. … September 25, 2019 WebM&M Cases Wrong-side Bedside Paravertebral … June 12, 2013 Cognitive error as the most frequent contributory factor in cases of medical

26. Changing the patient safety mindset: can safety cases help? | PSNet
    psnet.ahrq.gov/issue/changing-patient-safety-mindset-can-safety-cases-help
    July 14, 2021 - Commentary Changing the patient safety mindset: can safety cases help? … Changing the patient safety mindset: can safety cases help? … Changing the patient safety mindset: can safety cases help? … Download Citation Related Resources From the Same Author(s) Safety cases

27. Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases: a pragmatic randomized trial. | PSNet
    psnet.ahrq.gov/issue/impact-digitally-acquired-peer-diagnostic-input-diagnostic-confidence-outpatient-cases
    June 15, 2022 - Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases … Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases: a pragmatic … This intervention study evaluated the effect of peer input on diagnostic confidence on cases with diagnostic … In cases with high diagnostic uncertainly, peer input increased provider confidence. … Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases: a pragmatic

28. Impact of the percentage of overlapping surgery on patient outcomes: a retrospective cohort study of 87,000 surgical cases. | PSNet
    psnet.ahrq.gov/issue/impact-percentage-overlapping-surgery-patient-outcomes-retrospective-cohort-study-87000
    February 22, 2019 - percentage of overlapping surgery on patient outcomes: a retrospective cohort study of 87,000 surgical cases … percentage of overlapping surgery on patient outcomes: a retrospective cohort study of 87,000 surgical cases … This retrospective cohort study including over 87,000 surgical cases found that overlapping surgeries … increased in-hospital mortality, adverse events, or readmission rates when compared to nonoverlapping cases … percentage of overlapping surgery on patient outcomes: a retrospective cohort study of 87,000 surgical cases

29. Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision. | PSNet
    psnet.ahrq.gov/issue/care-post-roe-documenting-cases-poor-quality-care-dobbs-decision
    December 09, 2020 - Book/Report Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs … Citation Text: Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision. … This document reports the preliminary findings of a study examining 50 cases submitted where clinicians … Cite Citation Citation Text: Care Post-Roe: Documenting Cases … Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases

30. Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. | PSNet
    psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical-cases
    January 22, 2016 - Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases … Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. … This analysis of cases performed by a single neurosurgeon found that errors occurred frequently, most … Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. … September 21, 2009 Wrong-site craniotomy: analysis of 35 cases and systems for prevention

31. "ChatGPT, can you help me save my child's life?" - Diagnostic accuracy and supportive capabilities to lay rescuers by ChatGPT in prehospital basic life support and paediatric advanced life support cases - an in-silico analysis. | PSNet
    psnet.ahrq.gov/issue/chatgpt-can-you-help-me-save-my-childs-life-diagnostic-accuracy-and-supportive-capabilities
    February 01, 2023 - capabilities to lay rescuers by ChatGPT in prehospital basic life support and paediatric advanced life support cases … capabilities to lay rescuers by ChatGPT in prehospital basic life support and paediatric advanced life support cases … ChatGPT correctly recommended contacting medical professionals in all cases but only advised calling … The correct diagnosis was made in 94% of cases, consistent with other research into ChatGPT. … capabilities to lay rescuers by ChatGPT in prehospital basic life support and paediatric advanced life support cases

32. Malpractice cases in breast surgery: an assessment of litigation involving surgeons. | PSNet
    psnet.ahrq.gov/issue/malpractice-cases-breast-surgery-assessment-litigation-involving-surgeons
    August 04, 2021 - Study Malpractice cases in breast surgery: an assessment of litigation involving … Malpractice cases in breast surgery: an assessment of litigation involving surgeons. … While prior research has described malpractice cases related to breast cancer diagnosis and treatment … Malpractice cases in breast surgery: an assessment of litigation involving surgeons. … March 24, 2021 View More Related Resources WebM&M Cases

33. Selection Criteria and Honorarium Information | PSNet
    psnet.ahrq.gov/Webmm/submit-case-info
    August 10, 2025 - works Health care professionals may submit de-identified cases … Note that you can choose to submit cases either as a guest or … Cases including complete information can be processed more quickly (but note the word … Submitters of selected cases will receive a $300 honorarium paid anonymously through PayPal. … Track and save your case in My Cases. Register

34. Hospital-Level Gap Analysis for MRSA and SSI Prevention (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/132-gap-analysis-hospital-level.pdf
    April 01, 2025 - How are cases for SSIs associated with hip joint replacement detected? Check all that apply. …  Communication with patients via letters after discharge to identify cases  Other: 22. … How are cases for SSIs associated with spinal fusion detected? Check all that apply. … How are cases for SSIs associated with CABG with sternotomy detected? Check all that apply. … How are cases for SSIs associated with other types of surgery with sternotomy detected?

35. P-HIP Excel Tool Guidance (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/phip-mrabstraction-tool-guidance.pdf
    June 02, 2025 - Import a CSV file of cases to the current cases sheet. 3. … Data for all cases is saved as a CSV file. … to use all cases. 2 Earliest date. … Required if selecting cases by date. 4 View summary of selected cases on Score sheet. 5 View summary … and run chart of selected cases. 6 Use this column to indicate directly selected cases. 7 Discharge

36. Does learning from mistakes have to be painful? Analysis of 5 years' experience from the Leeds radiology educational cases meetings identifies common repetitive reporting errors and suggests acknowledging and celebrating excellence (ACE) as a more positive way of teaching the same lessons. | PSNet
    psnet.ahrq.gov/issue/does-learning-mistakes-have-be-painful-analysis-5-years-experience-leeds-radiology
    April 05, 2013 - Analysis of 5 years' experience from the Leeds radiology educational cases meetings identifies common … Analysis of 5 years' experience from the Leeds radiology educational cases meetings identifies common … able to identify numerous opportunities for improving learning from error, including using positive cases … Analysis of 5 years' experience from the Leeds radiology educational cases meetings identifies common … August 9, 2011 WebM&M Cases The Wet Read March 1,

37. Exhibit 20. Estimates of the total number of SSI cases in the United States, based on the rates used | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/ssi/ssiexh20.html
    April 01, 2018 - Estimates of the total number of SSI cases in the United States, based on the rates used Previous … Only 2 facilities performed coronary artery bypass grafting, with a pooled of just under 5,000 SSI cases … Hernia repair, performed by 3 facilities, give a national estimate of 1,000 cases or less from pooled … hip replacement (all 4 facilities) give an estimated national incidence of slightly over 5,000 SSI cases … data from all 4 facilities for total knee replacement give a national estimate of very close to 5,000 cases

38. Systematic review of malpractice litigation in the diagnosis and treatment of acute stroke | PSNet
    psnet.ahrq.gov/issue/systematic-review-malpractice-litigation-diagnosis-and-treatment-acute-stroke
    October 19, 2022 - Analyzing nearly 300 medical malpractice cases related to acute care of stroke patients, this review … The majority of cases resulted in no payout, but those that did result in payout saw an average settlement … 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

39. Delayed Diagnosis of Endocrinologic Emergencies | PSNet
    psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
    November 13, 2024 - The Cases Case #1: A 47-year-old man with a history of hyperthyroidism and hypertension presented … In a retrospective study, both factors contributed to diagnostic error in 46% of the cases.( 14 ) In … January 4, 2024 WebM&M Cases Delay in Malignancy … Mesenteric Ischemia August 31, 2022 WebM&M Cases … Duplicate Insulin Order March 1, 2019 WebM&M Cases

40. CRP Certification: Promoting Accountability and Learning After Adverse Events (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/gallagher5-report.pdf
    January 01, 2024 - In Washington, 81% of the cases were certified by the review panel, and four certified cases that were … Seventy percent of the Washington cases involved severe harm, including nine death cases. … Two thirds of the cases involved severe harm, including two death cases. … CRP Certification Cases Reviewed in Washington and California, 2016-2020 Location Cases reviewed … to date Cases Certified Severe harm cases (temporary severe harm or higher) Cases closed by