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41. Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error. | PSNet
    psnet.ahrq.gov/issue/hastened-death-due-disease-burden-and-distress-has-not-received-timely-quality-palliative
    October 31, 2023 - They highlight three cases in which patients in Canada requested medical assistance in dying (MAiD). … The patients in two of the cases were never offered palliative care services, and this could be considered … Text in the Electronic Health Records October 31, 2023 WebM&M Cases … July 8, 2020 WebM&M Cases The “Great Pretender” (Syphilis … February 12, 2020 WebM&M Cases Multiple Missed Opportunities

42. Berner ES et al. 1999 "Effects of a decision support system on physicians' diagnostic performance." | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/berner-es-et-al-1999
    January 01, 1999 - This study examines how the information provided by a diagnostic decision support system for clinical cases … Three sets of eight cases, stratified by diagnostic difficulty and the potential of [the system] to produce … Results: Physicians' diagnostic performance was significantly higher (p < 0.01) on the easier cases and … the cases for which [DDSS] could provide higher-quality information. … Performance was likely to be better for cases where the DDSS was displaying higher quality information

43. Using computerized virtual cases to explore diagnostic error in practicing physicians. | PSNet
    psnet.ahrq.gov/issue/using-computerized-virtual-cases-explore-diagnostic-error-practicing-physicians
    August 20, 2018 - Study Using computerized virtual cases to explore diagnostic error in practicing … Using computerized virtual cases to explore diagnostic error in practicing physicians. … This simulation study presented virtual patient cases to practicing physicians with the aim of improving … Using computerized virtual cases to explore diagnostic error in practicing physicians. … March 13, 2019 Teaching about diagnostic errors through virtual patient cases: a pilot

44. The hidden dangers of outsourcing radiology. | PSNet
    psnet.ahrq.gov/issue/hidden-dangers-outsourcing-radiology
    December 19, 2007 - July 3, 2013 WebM&M Cases The Dropped "No" October … 1, 2011 WebM&M Cases Duty to Disclose Someone … May 1, 2011 WebM&M Cases Right? Left? … May 1, 2006 WebM&M Cases The Wet Read March … 1, 2006 WebM&M Cases Techno Trip March 1,

45. Factors That Influence Effectiveness of Checklists | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-4.html
    September 01, 2020 - Checklists seem to help more in complex cases than in simple cases, 16 which is similar to studies on … as well. 18 Checklists may be more effective in difficult cases because there is more room for error … , 14 , 16 In such settings, potentially confounding factors such as case mix and complexity of the cases … Furthermore, studies in experimental settings often use complex cases, which reflect a different sample … Lastly, while in experimental studies participants are required to use the checklists on all cases they

46. Guide for Clinical Leaders: Calibrate Dx: A Resource To Improve Diagnostic Decisions (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/multiple/Calibrate-Dx-Clinical-Leaders-Guide.pdf
    September 01, 2022 - Calibrate Dx is a resource to help clinicians find and analyze cases in a structured way to gain insights … incorporate Calibrate Dx into their routine practice so they can consistently learn from different cases … Clinical leaders can model discussion of their own cases to bolster psychological safety. … � Help clinicians identify types of cases to review. … At the beginning, teams will often need help deciding which types of cases to review.

47. Final progress Report: Anticholinergics and Cognitive Decline in the Elderly with Depression (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/aparasu-report.pdf
    January 01, 2024 - Identification of Cases and Controls For specific aim 1, cases were identified as depression patients … The event date for the cases was defined as the date of the first ever diagnosis of dementia. … Cases and controls were matched on age (±1 year) and sex. … With matching, the distribution of age and sex was similar across cases and controls. … For the cognition objective, cases were defined based on the MDS cognition scale.

48. Training Education | PSNet
    psnet.ahrq.gov/training-education
    October 01, 2025 - In this section, you will have the opportunity to read WebM&M (Morbidity & Mortality) Spotlight Cases … Continuing Education: New Spotlight Cases Spotlight Case and Commentaries are certified for continuing … View All Spotlight Cases WebM&M Case Studies WebM&M (Morbidity … Spotlight Cases include interactive learning modules available for CME (Continuing Medical Education) … Olson, MD | March 25, 2025 This pair of cases describes patients misdiagnosed

49. Underdiagnosis of hypertension using electronic health records. | PSNet
    psnet.ahrq.gov/issue/underdiagnosis-hypertension-using-electronic-health-records
    November 16, 2022 - New cases of hypertension were frequently not diagnosed in a large ambulatory health care system, despite … March 15, 2017 View More Related Resources WebM&M Cases … April 19, 2017 WebM&M Cases Dual Therapy Debacle … September 1, 2015 WebM&M Cases It's Sarah, Not … July 26, 2011 WebM&M Cases Bad Writing, Wrong Medication

50. Medicare failed to investigate suspicious infection cases from 96 hospitals. | PSNet
    psnet.ahrq.gov/issue/medicare-failed-investigate-suspicious-infection-cases-96-hospitals
    May 29, 2019 - Newspaper/Magazine Article Medicare failed to investigate suspicious infection cases … Citation Text: Medicare failed to investigate suspicious infection cases from 96 hospitals. … Cite Citation Citation Text: Medicare failed to investigate suspicious infection cases

51. Friedman CP et al. 1999 "Enhancement of clinicians' diagnostic reasoning by computer-based consultation - a multisite study of 2 systems." | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/friedman-cp-et-al-1999
    January 01, 1999 - Reference (QMR; version 3.7.1), were used by participants for diagnostic evaluation of a total of 36 cases … and 45.4% of cases after consultation. … Workflow-Related Findings "A correct diagnosis appeared in subjects' hypothesis lists for 764 cases … (39.5%) before DSS consultation, increasing to 879 cases (45.4%) after consultation... … The overall consultation effect (net gain) is 115 cases (5.9%)...The largest consultation effects were

52. Complications of Vascular Access Procedures in Patients with Kidney Disease | PSNet
    psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
    November 15, 2023 - The Cases Three patients were at the same hospital over the course of a few months for vascular access … As a result of these first two cases, system-wide changes were implemented that included standardized … The cases presented above describe situations in which additional monitoring and staff could have been … Morbidity & Mortality meetings can also be helpful to discuss difficult cases and identify additional … November 16, 2022 WebM&M Cases Delayed Diagnosis

53. Role of communicating diagnostic uncertainty in the safety-netting process: insights from a vignette study. | PSNet
    psnet.ahrq.gov/issue/role-communicating-diagnostic-uncertainty-safety-netting-process-insights-vignette-study
    February 20, 2019 - 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

54. Duplicate Therapies in Retail Pharmacy | PSNet
    psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
    August 05, 2022 - The Cases Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection … In addition to opportunities for an improved patient counseling process, both cases reflect errors that … Adequate patient/caregiver counseling in both cases may have prevented these medication discrepancies … Close follow-up with a pharmacist occurred in both cases and led to identification and correction of … May 16, 2022 WebM&M Cases Wrong Catheter in the

55. AHRQ WebM&M—Online Medical Error Reporting and Analysis (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wachter.pdf
    March 11, 2005 - Cases will be of “near misses.” … Cases accompanied by detailed root cause analyses. … Online Error Reporting and Analysis 215 Cases.” … Just 1 percent of the cases came from the psychiatry field. … Adverse event/error types among published cases* Figure 1.

56. Management of Cardiac Arrest in Unconventional Locations. | PSNet
    psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
    June 14, 2023 - The Commentary By Garima Agrawal, MD, MPH, and Mithu Molla, MD, MBA Both of the cases described above … other cardiovascular emergencies through didactic instruction and active participation in simulated cases … November 15, 2018 WebM&M Cases No BP During NIBP … March 1, 2013 WebM&M Cases Anticoagulation … January 1, 2009 WebM&M Cases A Mid-Summer Fog

57. Mortality and risk factors associated with misdiagnosis of acute aortic syndrome in Ontario, Canada: a population-based study. | PSNet
    psnet.ahrq.gov/issue/mortality-and-risk-factors-associated-misdiagnosis-acute-aortic-syndrome-ontario-canada
    September 23, 2020 - Based on a retrospective cohort including 1,299 cases of AAS in Ontario, Canada, between 2003-2018, researchers … Mortality and surgical intervention were similar in missed and non-missed cases of AAS. … May 29, 2024 WebM&M Cases Under Pressure: Delayed Diagnosis … April 24, 2024 WebM&M Cases A Laceration that Needed … August 19, 2020 WebM&M Cases The NSTEMI Curbside Consultation

58. Missed Opportunities for Suicide Risk Assessment | PSNet
    psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
    September 27, 2023 - Systems Issues: In both of these cases, the patients did not receive adequate suicide risk assessment … It is also recommended that in cases when a patient cannot respond, reliable third-party information … June 14, 2023 WebM&M Cases A Fumbled Handoff to … Inpatient Rehab September 1, 2015 WebM&M Cases … June 14, 2023 WebM&M Cases Challenging Case of

59. Final Progress Report: Unexpected Clinical Events: Impact on Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/2024-12/weinger2-report.pdf
    January 01, 2024 - Demographic attributes of videotaped cases Case Attributes No NRE Cases (n=265) NRE Cases (n=139) Sig … 19% (36/187) of NRE (8.9% of all cases). … , representing 10.6% of all cases. … Seven cases led to patient injury. … During 20 noncardiac cases and 15 cardiac cases, drug/fluid tasks comprised 8% of induction and 7% of

60. Inadequate Preanesthetic Evaluation, Airway Trouble | PSNet
    psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
    November 01, 2023 - The morning gynecology surgery list was overbooked with five cases, a mixture of ambulatory cases and … inpatient cases. … degree of potential difficulty with placing an endotracheal tube ( Table 2 ).( 4,5 ) In these two cases … December 14, 2022 WebM&M Cases Open wider: Failure … December 14, 2022 WebM&M Cases Fecal Contamination