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  1. psnet.ahrq.gov/issue/assigning-responsibility-close-loop-radiology-test-results
    April 03, 2024 - Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases … July 26, 2023 WebM&M Cases Medication Reconciliation … August 28, 2017 WebM&M Cases Delayed Recognition of a … Positive Blood Culture July 1, 2017 WebM&M Cases … March 18, 2010 WebM&M Cases The Result Stopped Here
  2. psnet.ahrq.gov/issue/use-and-implementation-standard-operating-procedures-and-checklists-prehospital-emergency
    August 28, 2024 - June 14, 2017 WebM&M Cases Misleading Complaint July … 1, 2012 WebM&M Cases All in the History March … February 27, 2009 WebM&M Cases X-ray Flip February … 1, 2004 WebM&M Cases Charcoal Lavage of the Lungs … October 1, 2003 WebM&M Cases Code Status Confusion
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37095/psn-pdf
    September 04, 2010 - Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. … Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. … https://psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical- cases … This analysis of cases performed by a single neurosurgeon found that errors occurred frequently, most … https://psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical-cases
  4. psnet.ahrq.gov/web-mm/spinal-epidural-abscess
    November 13, 2019 - A quality improvement approach to reduce harm from cases like this one may include identifying cases … Additionally, the protocol ensured that the thoracic level was imaged in all cases of suspected SEA. … June 18, 2014 WebM&M Cases Bowel Prep July 1, 2004 … WebM&M Cases Hidden Mystery March 1, 2005 … a Proper Exam, Not an X-Ray January 31, 2024 WebM&M Cases
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45415/psn-pdf
    June 25, 2018 - Association of overlapping surgery with patient outcomes in a large series of neurosurgical cases. … Association of Overlapping Surgery With Patient Outcomes in a Large Series of Neurosurgical Cases. … /psnet.ahrq.gov/issue/association-overlapping-surgery-patient-outcomes-large-series-neurosurgical- cases … This single-center retrospective study of 2275 neurosurgery cases at an academic medical center compared … ://psnet.ahrq.gov/issue/association-overlapping-surgery-patient-outcomes-large-series-neurosurgical-cases
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43936/psn-pdf
    December 04, 2015 - Exploring the Potential Use of Safety Cases in Health Care. … December 4, 2015 Safety Cases Working Group. London, UK: Health Foundation; 2015. … https://psnet.ahrq.gov/issue/exploring-potential-use-safety-cases-health-care This report describes … a consensus-building initiative in the United Kingdom seeking to determine ways safety cases can be … The results explain how to utilize cases to introduce changes, improve services, and enhance safety
  7. www.uspreventiveservicestaskforce.org/uspstf/recommendation/syphilis-infection-in-pregnancy-screening
    May 13, 2025 - cases per 100,000 live births in Black women 125.0 cases per 100,000 live births in Hispanic/Latina … cases in 2023. 2 , 4 It is estimated that almost 90% of new congenital syphilis cases could have been … per 100,000 live births in Asian women, 222.0 cases per 100,000 live births in Black women, 125.0 cases … A recent analysis of national data from 2022 found that 5% of congenital syphilis cases (197/3761 cases … Factors contributing to congenital syphilis cases - New York City, 2010-2016.
  8. psnet.ahrq.gov/web-mm/x-ray-flip
    August 10, 2019 - Figure Related Resources From the Same Author(s) WebM&M Cases … July 23, 2010 WebM&M Cases Delay in Treatment: Failure … May 1, 2011 WebM&M Cases All in the History … Lavage of the Lungs October 1, 2003 WebM&M Cases … Code Status Confusion July 1, 2003 WebM&M Cases
  9. psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
    April 28, 2021 - that injury to the bowel or major vessels during laparoscopic procedures occurs in about 3 per 1000 cases … 28, 2021 WebM&M Cases Did We Forget Something? … October 7, 2021 WebM&M Cases Two Cases of Retained Vaginal … December 22, 2010 WebM&M Cases Resuscitation Errors: … A Shocking Problem August 21, 2007 WebM&M Cases
  10. psnet.ahrq.gov/issue/thinking-threes-changing-surgical-patient-safety-practices-complex-modern-operating-room
    April 28, 2021 - Download Citation Related Resources From the Same Author(s) WebM&M Cases … Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough April … 28, 2021 WebM&M Cases Did We Forget Something? … September 1, 2003 WebM&M Cases Procedural Mishap … March 30, 2022 WebM&M Cases Sudden Collapse During Upper
  11. psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
    January 29, 2021 - History Leads to Adverse Outcomes July 8, 2022 WebM&M Cases … March 29, 2023 WebM&M Cases Distraction of the … March 15, 2023 WebM&M Cases Open wider: Failure … March 15, 2023 WebM&M Cases Open wider: Failure … February 9, 2022 WebM&M Cases To Dilute or Not Dilute
  12. psnet.ahrq.gov/web-mm/coming-short
    May 20, 2020 - February 1, 2010 WebM&M Cases Failure to Latch … September 1, 2008 WebM&M Cases It's All in the … Syringe August 1, 2006 WebM&M Cases A "Weak … " Response December 1, 2004 WebM&M Cases The … a Tough Position October 1, 2003 WebM&M Cases
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40113/psn-pdf
    December 21, 2014 - Working with a fixed operating room team on consecutive similar cases and the effect on case duration … Working with a fixed operating room team on consecutive similar cases and the effect on case duration … https://psnet.ahrq.gov/issue/working-fixed-operating-room-team-consecutive-similar-cases-and-effect-case … - duration-and Team continuity for surgical cases resulted in improved efficiency in this study conducted … https://psnet.ahrq.gov/issue/working-fixed-operating-room-team-consecutive-similar-cases-and-effect-case-duration-and
  14. psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
    January 29, 2021 - March 29, 2023 WebM&M Cases Distraction of the … March 15, 2023 WebM&M Cases Open wider: Failure … May 15, 2024 WebM&M Cases Open wider: Failure to use … October 27, 2022 WebM&M Cases Delayed Diagnosis … June 3, 2020 WebM&M Cases Residual Anesthesia: Tepid
  15. psnet.ahrq.gov/issue/clinical-pathway-adherence-and-missed-diagnostic-opportunities-among-children-musculoskeletal
    November 08, 2023 - July 10, 2024 WebM&M Cases A Laceration that Needed a … Proper Exam, Not an X-Ray January 31, 2024 WebM&M Cases … March 15, 2023 WebM&M Cases Spinal Epidural Abscess … October 30, 2017 WebM&M Cases Failed Interpretation of … Screening Tool: Delayed Treatment September 1, 2017 WebM&M Cases
  16. digital.ahrq.gov/ahrq-funded-projects/veterans-administration-va-integrated-medication-manager/annual-summary/2010
    January 01, 2010 - The second phase of the project evaluates the IMM software using test cases in simulation studies. … The research team completed creating, pilot testing, and revising all test cases. … The team’s approach to creating test cases changed based on lessons learned in building the first case … The team initially thought creating test cases would be more difficult than using real patient cases … Real patient cases are, in fact, too complex to be used for the tests.
  17. psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient
    July 19, 2023 - Pancreatitis following olanzapine therapy: a report of three cases. … August 4, 2021 WebM&M Cases The Hazards of Distraction … : Ticking All the EHR Boxes February 1, 2017 WebM&M Cases … June 14, 2023 WebM&M Cases Discharge Fumbles … Don't Push November 1, 2003 WebM&M Cases
  18. psnet.ahrq.gov/web-mm/premature-or-overdue
    December 23, 2020 - In cases like this one, the first assessment by a new on-duty team should include a reconfirmation of … Care Status December 23, 2020 WebM&M Cases … October 20, 2021 WebM&M Cases Culture Clash No More: … Treat Thyself September 1, 2004 WebM&M Cases … Heterotopic Pregnancy January 1, 2004 WebM&M Cases
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44858/psn-pdf
    February 10, 2016 - Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting … Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting … https://psnet.ahrq.gov/issue/situation-awareness-errors-anesthesia-and-critical-care-200-cases-critical … - incident-reporting This retrospective review of anesthesia and critical care cases in the German … https://psnet.ahrq.gov/issue/situation-awareness-errors-anesthesia-and-critical-care-200-cases-critical-incident-reporting
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40767/psn-pdf
    September 14, 2011 - Mislabeling of cases, specimens, blocks, and slides: a College of American Pathologists study of 136 … Mislabeling of cases, specimens, blocks, and slides: a college of american pathologists study of 136 … https://psnet.ahrq.gov/issue/mislabeling-cases-specimens-blocks-and-slides-college-american- pathologists-study … across 136 institutions, this study quantified mislabeling rates at a cumulative total of 0.11% for cases … https://psnet.ahrq.gov/issue/mislabeling-cases-specimens-blocks-and-slides-college-american-pathologists-study