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  1. Emergency department image interpretation accuracy: the influence of immediate reporting by radiology. | PSNet

    psnet.ahrq.gov/issue/emergency-department-image-interpretation-accuracy-influence-immediate-reporting-radiology
    November 09, 2022 - August 17, 2022 WebM&M Cases Coming up for Err: Missed … a Patient with Recurrent Pneumothorax August 25, 2021 WebM&M Cases … September 26, 2012 WebM&M Cases Duty to Disclose Someone … June 23, 2009 WebM&M Cases X-ray Flip February 1, … 2004 WebM&M Cases The Dropped Lung May 1,

  2. Factors associated with potentially missed diagnosis of appendicitis in the emergency department. | PSNet

    psnet.ahrq.gov/issue/factors-associated-potentially-missed-diagnosis-appendicitis-emergency-department
    December 16, 2020 - August 7, 2024 WebM&M Cases Bandemia as a Harbinger of … Stercoral Colitis and Impending Perforation July 31, 2023 WebM&M Cases … March 22, 2014 WebM&M Cases A Real Heartache December … 1, 2012 WebM&M Cases Missed Pneumonia November … October 20, 2010 WebM&M Cases Pregnant With Danger

  3. Diagnostic challenges in primary care: identifying and avoiding cognitive bias. | PSNet

    psnet.ahrq.gov/issue/diagnostic-challenges-primary-care-identifying-and-avoiding-cognitive-bias
    November 03, 2021 - Improving Diagnostic Safety and Quality April 26, 2023 WebM&M Cases … June 30, 2021 WebM&M Cases Paroxysmal Supraventricular … Tachycardia Masquerading as Panic Attacks June 30, 2021 WebM&M Cases … Care: Remembering the Physical Examination March 31, 2021 WebM&M Cases … December 23, 2020 WebM&M Cases Endometriosis: A

  4. Blind Spot | PSNet

    psnet.ahrq.gov/web-mm/blind-spot
    July 30, 2020 - The Commentary This case illustrates the insidious and surprising nature of many cases of postoperative … In just over half of the ION cases in the ASA POVL Registry, both eyes were affected, consistent with … Spine surgery cases with ION in the ASA POVL Registry are associated with large operative blood loss … Most cases of PION do not progress in the postoperative period if the patient has stable hemodynamics … However, many of these cases are thought to be caused by particulate emboli and thus may not be easily

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865479/psn-pdf
    April 03, 2024 - 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.

  6. Development and psychometric analysis of a patient-reported measure of diagnostic excellence for emergency and urgent care settings. | PSNet

    psnet.ahrq.gov/issue/development-and-psychometric-analysis-patient-reported-measure-diagnostic-excellence
    January 10, 2024 - January 10, 2024 WebM&M Cases Paroxysmal Supraventricular … initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases … October 23, 2019 WebM&M Cases Hiding in Plain Sight … August 1, 2009 WebM&M Cases Autopsy Revelation … March 1, 2004 WebM&M Cases Missed Appendicitis

  7. Patients should know who's operating, surgeons say. | PSNet

    psnet.ahrq.gov/issue/patients-should-know-whos-operating-surgeons-say
    May 15, 2024 - June 8, 2022 WebM&M Cases "Do You Want Everything Done … March 18, 2010 WebM&M Cases Secured But Not Always Safe … November 1, 2006 WebM&M Cases DNR in the OR … and Afterwards September 1, 2006 WebM&M Cases

  8. Hold the tPA | PSNet

    psnet.ahrq.gov/web-mm/hold-tpa
    July 29, 2020 - November 15, 2018 WebM&M Cases The Forgotten Turn … Privacy Gone Awry May 1, 2004 WebM&M Cases … December 1, 2008 WebM&M Cases Recurrent Hypoglycemia: … October 1, 2008 WebM&M Cases One ACE Too Many … July 1, 2006 WebM&M Cases Lost in Transition

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36993/psn-pdf
    September 15, 2011 - A transdisciplinary team acting on evidence through analyses of moot malpractice cases. … A transdisciplinary team acting on evidence through analyses of moot malpractice cases. … https://psnet.ahrq.gov/issue/transdisciplinary-team-acting-evidence-through-analyses-moot-malpractice- cases … https://psnet.ahrq.gov/issue/transdisciplinary-team-acting-evidence-through-analyses-moot-malpractice-cases … https://psnet.ahrq.gov/issue/transdisciplinary-team-acting-evidence-through-analyses-moot-malpractice-cases

  10. Confusion With Acetaminophen | PSNet

    psnet.ahrq.gov/web-mm/confusion-acetaminophen
    December 01, 2009 - October 1, 2008 WebM&M Cases Raise the Bar … April 1, 2006 WebM&M Cases Lethal Cap … March 1, 2004 WebM&M Cases Undiagnosed Vaginal … Push November 1, 2003 WebM&M Cases Making … June 1, 2003 WebM&M Cases Missed Appendicitis

  11. Misread Label | PSNet

    psnet.ahrq.gov/web-mm/misread-label
    August 28, 2024 - The Wrong Shot: Error Disclosure June 1, 2004 WebM&M Cases … Lethal Cap March 1, 2004 WebM&M Cases … June 1, 2003 WebM&M Cases Medication Overdose … April 1, 2003 WebM&M Cases The 2-Week Itch … April 1, 2003 WebM&M Cases Unexplained Apnea

  12. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. | PSNet

    psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
    January 29, 2021 - History Leads to Adverse Outcomes July 8, 2022 WebM&M Cases … March 29, 2023 WebM&M Cases Open wider: Failure … to Arterial Thrombosis June 28, 2023 WebM&M Cases … March 15, 2023 WebM&M Cases Open wider: Failure … July 28, 2021 WebM&M Cases Fumbled Handoff

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865967/psn-pdf
    May 29, 2024 - 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.

  14. Hyponatremia Secondary to Home Parenteral Nutrition Error | PSNet

    psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
    May 27, 2020 - September 23, 2020 WebM&M Cases Getting the Diagnosis … Both Right and Wrong September 25, 2019 WebM&M Cases … June 16, 2019 WebM&M Cases Unintended Consequences of … CPOE October 1, 2016 WebM&M Cases Sick and … Pregnant November 1, 2008 WebM&M Cases Two

  15. Raise the Bar | PSNet

    psnet.ahrq.gov/web-mm/raise-bar
    May 29, 2024 - A new approach to preanesthetic site verification after 2 cases of wrong site peripheral nerve blocks … January 26, 2022 WebM&M Cases To Dilute or Not Dilute … Pocket Syringe Swap May 1, 2011 WebM&M Cases … 1, 2004 WebM&M Cases Listen to the Family … June 1, 2004 WebM&M Cases Too Tight Control

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36868/psn-pdf
    August 29, 2011 - Quali-quantitative analysis: a new model for evaluation of unusual cases in hospital performance? … Quali-quantitative analysis: a new model for evaluation of unusual cases in hospital performance? … https://psnet.ahrq.gov/issue/quali-quantitative-analysis-new-model-evaluation-unusual-cases-hospital- … https://psnet.ahrq.gov/issue/quali-quantitative-analysis-new-model-evaluation-unusual-cases-hospital-performance … https://psnet.ahrq.gov/issue/quali-quantitative-analysis-new-model-evaluation-unusual-cases-hospital-performance

  17. Ectopic or Not? | PSNet

    psnet.ahrq.gov/web-mm/ectopic-or-not
    March 27, 2024 - November 25, 2020 WebM&M Cases Misdiagnosis of … Insert Omission April 1, 2006 WebM&M Cases … Poor Prognosis September 1, 2004 WebM&M Cases … The Other Side October 1, 2003 WebM&M Cases … Not a Miscarriage June 1, 2003 WebM&M Cases

  18. Intraoperative Awareness during Rhinoplasty | PSNet

    psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
    January 29, 2021 - A closed claims analysis reported 61 cases of awareness during general anesthesia; only 9 of these cases … World J Clin Cases . 2020;8(2):245-254. [ Free full text ] Chung HS. … 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

  19. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning | PSNet

    psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
    January 29, 2021 - The Missing Bedside Examination When doctors recall cases in which they missed a diagnosis, they frequently … retrospective study in Japan found that delayed diagnosis occurred in 31% of their perforated bowel cases … May 16, 2022 WebM&M Cases Challenges of Diabetes … Echocardiogram Result Lost to Follow-up June 14, 2023 WebM&M Cases … When the Meds Don’t Reach the Bed August 26, 2020 WebM&M Cases

  20. Round-Trip Service | PSNet

    psnet.ahrq.gov/web-mm/round-trip-service
    April 26, 2023 - September 12, 2016 WebM&M Cases Infused, Not Ingested … 1, 2003 WebM&M Cases Slow Down: Right Drug, Wrong … of Error May 1, 2006 WebM&M Cases Root Cause … May 8, 2013 WebM&M Cases Tacit Handover, Overt Mishap … Do September 1, 2003 WebM&M Cases Suicidal
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