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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - Getting the Diagnosis Both Right and Wrong
Citation Text:
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/issue/system-related-interventions-reduce-diagnostic-errors-narrative-review
May 29, 2015 - investigators found that few of the interventions proposed to address these issues have been formally tested
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - SPOTLIGHT CASE
Delayed Diagnosis of Mesenteric Ischemia
Citation Text:
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.
Citation Text:
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/issue/development-and-implementation-cognitive-aids-critical-events-pediatric-anesthesia-society
September 27, 2017 - Commentary
The development and implementation of cognitive aids for critical events in pediatric anesthesia: the Society for Pediatric Anesthesia Critical Events Checklists.
Citation Text:
Clebone A, Burian BK, Watkins SC, et al. The Development and Implementation of Cognitive Aids for C…
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
February 22, 2023 - Also, the use of a diagnostic time out, an intentional pause to consider alternate diagnoses, was tested … that contribute to diagnostic error, interventions that seek to mitigate error are being developed and tested
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psnet.ahrq.gov/issue/thinking-fast-and-slow-medicine
June 21, 2017 - Commentary
Thinking fast and slow in medicine.
Citation Text:
Michel JB. Thinking fast and slow in medicine. Baylor U Med Center Proceed. 2019;33(1):123-125. doi:10.1080/08998280.2019.1674043.
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - SPOTLIGHT CASE
Delirium or Dementia?
Citation Text:
Rudolph JL. Delirium or Dementia?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - Annual Perspective
Diagnostic Errors
Urmimala Sarkar, MD; Kaveh Shojania, MD | January 1, 2014
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Citation Text:
Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
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psnet.ahrq.gov/issue/managing-interruptions-improve-diagnostic-decision-making-strategies-and-recommended-research
February 24, 2021 - This article reviews empirically-tested strategies from healthcare and cognitive psychology that can
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psnet.ahrq.gov/issue/missed-and-delayed-diagnoses-ambulatory-setting-study-closed-malpractice-claims
October 26, 2010 - Study
Classic
Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims.
Citation Text:
Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. An…
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psnet.ahrq.gov/issue/communicating-critical-test-results
May 24, 2006 - Special or Theme Issue
Communicating Critical Test Results.
Citation Text:
Communicating Critical Test Results. Schiff GD, Bates DW, Leape LL, eds. Jt Comm J Qual Patient Saf. 2005;31(2):62-119.
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - tendons impart different movements depending on the phalanx or joint assessed, each tendon must be tested
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psnet.ahrq.gov/issue/examining-meaning-language-used-communicate-nursing-hand
July 07, 2021 - Study
Examining the meaning of the language used to communicate the nursing hand-off.
Citation Text:
Galatzan BJ, Carrington JM. Examining the meaning of the language used to communicate the nursing hand‐off. Res Nurs Health. 2021;44(5):833-843. doi:10.1002/nur.22175.
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psnet.ahrq.gov/issue/measuring-and-improving-diagnostic-safety-primary-care-addressing-twin-pandemics-diagnostic
September 07, 2022 - Commentary
Measuring and improving diagnostic safety in primary care: addressing the “twin” pandemics of diagnostic error and clinician burnout.
Citation Text:
Olson APJ, Linzer M, Schiff GD. Measuring and Improving Diagnostic Safety in Primary Care: Addressing the “Twin” Pandemics of Di…
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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common?
Mark L. Graber, MD | February 1, 2007
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Citation Text:
Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpi…
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - SPOTLIGHT CASE
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
Citation Text:
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
February 21, 2020 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.
Citation Text:
Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/node/49673/psn-pdf
December 01, 2012 - A Real Heartache
December 1, 2012
Polevoi SK. A Real Heartache. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/real-heartache
The Case
A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The
pain began at rest, and it radiated to his back and left axilla. He had…