-
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
-
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
-
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
-
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
-
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
-
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
-
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.
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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.
-
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
-
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
-
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
-
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