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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Medication Mix-Up Leads to Patient Death
Citation Text:
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - SPOTLIGHT CASE
Despite Clues, Failed to Rescue
Citation Text:
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
September 01, 2004 - The Case
A 60-year-old woman with a history of metastatic colon cancer and known malignant ascites
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psnet.ahrq.gov/node/866261/psn-pdf
July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy
Position for Laparoscopic Gynecological Surgery
July 10, 2024
Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic
Gynecological Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/missed-compartment-syndrome…
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psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
January 29, 2020 - Delayed Recognition of a Positive Blood Culture
Citation Text:
Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/perspective/what-makes-good-checklist
October 01, 2010 - That's about the same number of people that die from colon cancer.
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
October 01, 2010 - That's about the same number of people that die from colon cancer.
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psnet.ahrq.gov/node/838221/psn-pdf
September 28, 2022 - has diabetes that’s out of control with an elevated hemoglobin
A1c, or when someone never got their colon … cancer screening, the health worker can be pinged for their
panel of patients and reach out to intervene
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psnet.ahrq.gov/node/49799/psn-pdf
July 01, 2017 - Delayed Recognition of a Positive Blood Culture
July 1, 2017
Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
The Case
A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…
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psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
January 29, 2021 - Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery
Citation Text:
Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qual…
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - March 11, 2020
WebM&M Cases
Anemia and Delayed Colon … Cancer Diagnosis
August 10, 2019
WebM&M Cases
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - has diabetes that’s out of control with an elevated hemoglobin A1c, or when someone never got their colon … cancer screening, the health worker can be pinged for their panel of patients and reach out to intervene