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psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - November 21, 2021
WebM&M Cases
Turn the Other Cheek … February 10, 2021
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Hip Fractures in Older … November 5, 2014
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Discontinued Medications … May 1, 2014
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Discharge Instructions … June 1, 2012
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Patient Safety and
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psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - Most cases are associated with hemostatic abnormalities, either patient-related or iatrogenic.( 8 ) In … Although cases also have been reported with unfractionated heparin, the complication is much less common … September 1, 2006
WebM&M Cases
Right? … May 1, 2006
WebM&M Cases
On O.R. Off? … 1, 2004
WebM&M Cases
Too Tight Control
May
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psnet.ahrq.gov/node/36701/psn-pdf
January 18, 2011 - Error and patient safety: ethical analysis of cases in
occupational and physical therapy practice. … Error and patient safety: ethical analysis of cases in occupational and
physical therapy practice. … https://psnet.ahrq.gov/issue/error-and-patient-safety-ethical-analysis-cases-occupational-and-physical … https://psnet.ahrq.gov/issue/error-and-patient-safety-ethical-analysis-cases-occupational-and-physical-therapy-practice … https://psnet.ahrq.gov/issue/error-and-patient-safety-ethical-analysis-cases-occupational-and-physical-therapy-practice
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psnet.ahrq.gov/issue/noahs-story-please-listen
June 27, 2018 - July 29, 2009
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WebM&M Cases … January 18, 2023
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Open wider: Failure to … November 4, 2015
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Residual Anesthesia: Tepid … Burn
August 1, 2012
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Routine Goes … April 1, 2006
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Privacy Gone Awry
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psnet.ahrq.gov/web-mm/silent-pain-neck
August 19, 2020 - It is important to emphasize that cases of delayed hemorrhage, occurring 24 hours or more after thyroid … In cases of airway obstruction secondary to hematoma, immediate intubation should be performed by an … March 29, 2023
WebM&M Cases
Respiratory Distress … after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. … December 15, 2011
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The Forgotten Turn
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psnet.ahrq.gov/web-mm/more-treatment-better-care
August 11, 2021 - While there is no cure, most cases recover with time on their own. … August 11, 2021
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Don't Pick the PICC … December 1, 2012
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Peripheral IV in … of Cross Coverage
May 1, 2012
WebM&M Cases … Poorly Advanced Directives
February 1, 2012
WebM&M Cases
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psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
February 23, 2022 - specific. 6 Positioning of the CVC was in agreement between ultrasound and chest x-ray in 98.9% of cases … In the largest published series of 236 cases of CVC guidewire retention from England’s “Never Event” … unstable patients. distraction and operator skill as major reasons for this complication. 12 In all cases … operation, or information about another sick patient. 13 In the great majority of these and other cases … March 17, 2021
WebM&M Cases
Benefits vs.
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psnet.ahrq.gov/node/60241/psn-pdf
February 24, 2022 - number of weekly cases and
deaths to date in the pandemic, rising to 5,333 confirmed cases and 565 deaths … There was an even greater increase in staff cases,
from 495 confirmed cases and 5 deaths at the lowest … State Reporting of Cases and Deaths Due to COVID-19 in Long-Term Care
Facilities. … Is there a link between nursing home reported quality and COVID-19 cases? … Nursing Home Resident and Staff Covid-19 Cases After the First
Vaccination Clinic.
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psnet.ahrq.gov/web-mm/double-dose-transfer
November 01, 2012 - 1, 2004
WebM&M Cases
Abdominal Aortic Aneurysm … in Plain Sight
August 1, 2009
WebM&M Cases … December 1, 2014
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Missed Pneumonia … June 1, 2012
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Treatment Challenges … After Discharge
November 1, 2010
WebM&M Cases
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hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/or22.jsp
July 01, 2014 - Within Group 1, there is as subgroup labeled Cases Coded as A I A N, n = 2007. … classified = 1060, and Matched A I A N cases, race incorrectly classified n = 959. … Graphic - Row 1, right: Race coding among misclassified cases. Pie chart. … Graphic - Row 2, right: Number of S T D cases by year, Oregon A I A N. Bar chart. … high number of cases that were of unknown or missing race
Unmatched AI/AN cases were more likely to
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psnet.ahrq.gov/issue/retrospective-analysis-demonstrates-failure-document-key-comorbid-diseases-anesthesia
May 26, 2021 - Download Citation
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WebM&M Cases … September 22, 2021
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Endometriosis: A Common … and Commonly Missed and Delayed Diagnosis
June 24, 2020
WebM&M Cases … August 12, 2020
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Multiple Missed Opportunities … March 10, 2011
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Around the Block
March
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psnet.ahrq.gov/issue/commercialised-experience-operating-embodied-preferences-ambiguous-variations-and-explaining
August 24, 2022 - August 31, 2022
WebM&M Cases
Nothing Called Small Surgery … April 4, 2011
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Impatient Inpatient Dosing … August 21, 2005
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Lap Burn … October 1, 2004
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Ectopic or Not? … May 1, 2003
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Procedural Mishap: Learning
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psnet.ahrq.gov/issue/improving-emergency-medicine-clinician-awareness-prehospital-administered-medications
October 19, 2022 - May 8, 2024
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WebM&M Cases … May 29, 2024
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Weight and Height Juxtaposition … May 24, 2023
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The Dose Makes the Poison: … November 16, 2022
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EMS Perils from Hospital … Overcrowding
August 31, 2022
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - December 3, 2008
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Multiple Levels Involved … November 15, 2023
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Critical Echocardiogram … December 14, 2022
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Open wider: Failure to … December 14, 2022
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Delayed Diagnosis … Routine Goes Awry
June 1, 2011
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psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
January 29, 2021 - History Leads to Adverse Outcomes
July 8, 2022
WebM&M Cases … March 29, 2023
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Distraction of the … to Arterial Thrombosis
June 28, 2023
WebM&M Cases … Anterior Cervical Spine Surgery
February 28, 2024
WebM&M Cases … December 14, 2022
WebM&M Cases
Don’t Bite Your Tongue
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psnet.ahrq.gov/node/61089/psn-pdf
January 01, 2021 - In this analysis of over 700 general surgical cases
with complications, the authors attributed cognitive … bias in one-third of all cases. … These cases were also
associated with an increase in management errors (e.g., diagnostic, communication
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psnet.ahrq.gov/node/837855/psn-pdf
August 17, 2022 - study,
pathologists and pathology residents were asked to diagnose surgical pathology or cytopathology cases … Most respondents provided the correct diagnosis for most of the cases; 35% of
cases were wholly or partially
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psnet.ahrq.gov/issue/implementation-comprehensive-unit-based-safety-program-reduce-surgical-site-infections
December 20, 2023 - June 21, 2023
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WebM&M Cases … Cardiac Arrests and Emergency Hysterectomy
March 27, 2024
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Two Cases of Retained … September 11, 2019
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Waiting Too Long
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psnet.ahrq.gov/node/37424/psn-pdf
May 25, 2011 - Responding to serious medical error in general
practice—consequences for the GPs involved: analysis of
75 cases … Responding to serious medical error in general practice--consequences
for the GPs involved: analysis of 75 cases … psnet.ahrq.gov/issue/responding-serious-medical-error-general-practice-consequences-gps-
involved-analysis-75-cases … psnet.ahrq.gov/issue/responding-serious-medical-error-general-practice-consequences-gps-involved-analysis-75-cases … psnet.ahrq.gov/issue/responding-serious-medical-error-general-practice-consequences-gps-involved-analysis-75-cases
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psnet.ahrq.gov/node/39823/psn-pdf
April 04, 2011 - Cognitive error as the most frequent contributory factor in
cases of medical injury: a study on verdict's … Cognitive error as the most frequent contributory factor in cases of
medical injury: a study on verdict's … https://psnet.ahrq.gov/issue/cognitive-error-most-frequent-contributory-factor-cases-medical-injury-study … https://psnet.ahrq.gov/issue/cognitive-error-most-frequent-contributory-factor-cases-medical-injury-study-verdicts … https://psnet.ahrq.gov/issue/cognitive-error-most-frequent-contributory-factor-cases-medical-injury-study-verdicts