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psnet.ahrq.gov/issue/delayed-workup-rectal-bleeding-adult-primary-care-examining-process-care-failures
April 24, 2018 - Rectal bleeding is an important issue to recognize promptly, because it may be a symptom of colon cancer … Use of administrative data to find substandard care: validation of the complications screening
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psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
September 28, 2022 - The community had an understanding that testing to prevent colon cancer was important. … You notice that I changed the language there from “colorectal cancer” to “colon cancer.” … When we actually worked with a group of community members , they said “colon cancer” screening. … So, they changed the language from “colorectal cancer screening” to “testing to prevent colon cancer. … People were coming in saying, “I’m here to get tested to prevent colon cancer.”
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - cancer safety net.1 The ASN was constructed for colon cancer by creating a quality metric to track … cancer and lung cancer, and (2) to build a system from the point of test-ordering to the completion … The colon cancer safety net was constructed based on
prior colonoscopy procedures. … Overall, the effectiveness of the colon cancer safety net was 44% and the lung cancer safety net was … collaborative.”1
Innovation Patient Safety Focus
The lack of necessary clinical follow-up after a key cancer screening
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psnet.ahrq.gov/issue/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
May 12, 2021 - is illustrated with three diagnoses: ectopic pregnancy , abdominal aortic aneurysms , and advanced colon … cancer. … May 12, 2021
Multilevel factors associated with time to biopsy after abnormal screening
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psnet.ahrq.gov/node/49798/psn-pdf
July 01, 2017 - to be 2.6/1000, 0.5/1000, and 2.9/100,000, respectively.(8) The risk of complications is lower for
screening … Screening for colorectal cancer: a targeted, updated
systematic review for the U.S.
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - to be 2.6/1000, 0.5/1000, and 2.9/100,000, respectively.( 8 ) The risk of complications is lower for screening … Screening for colorectal cancer: a targeted, updated systematic review for the U.S.
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psnet.ahrq.gov/periodic-issue/periodic-issue-401
July 31, 2023 - Study
Breast cancer missed at screening; hindsight or mistakes? … Using a national breast cancer registry, researchers reread negative screening mammograms of women diagnosed … with breast cancer in the two years following the screening. … Screening mammograms were then rated as true negative (i.e., no cancer could be detected) or missed ( … Among women with screen-detected or interval cancer, most initial screening mammograms did not show visible
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psnet.ahrq.gov/web-mm/inflicting-confusion
August 04, 2021 - This risk mandates screening of all patients for tuberculosis prior to initiation of therapy. … Screening can take place either by purified protein derivative (PPD) or QuantiFERON-TB Gold testing, … Stool culture, CDI testing, and screening for ova and parasites should be considered at admission for … August 31, 2022
WebM&M Cases
Anemia and Delayed Colon … Cancer Diagnosis
August 10, 2019
WebM&M Cases
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psnet.ahrq.gov/periodic-issue/periodic-issue-402
August 30, 2023 - Study
The impact of primary care providers' bias on depression screening for lesbian … Regular depression screening is recommended for all adults. … relationship of primary care providers' (PCP) bias towards lesbian women and recommendations for depression screening … Providers who recommended screening showed slightly more positive explicit attitudes and slightly lower … report shares recommendations to address leadership failures and other deficiencies including poor screening
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psnet.ahrq.gov/node/851555/psn-pdf
July 31, 2023 - Bandemia as a Harbinger of Stercoral Colitis and
Impending Perforation
July 31, 2023
Flynn S, Barnes DK. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
The Case
A 56-year-…
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - The community had an understanding that testing to prevent colon cancer was important. … You notice that I changed the language there from “colorectal cancer” to “colon cancer.” … When we actually worked with a group of community members , they said “colon cancer” screening. … So, they changed the language from “colorectal cancer screening” to “testing to prevent colon cancer. … People were coming in saying, “I’m here to get tested to prevent colon cancer.”
-
psnet.ahrq.gov/periodic-issue/periodic-issue-406
August 30, 2023 - Study
Estimating breast cancer overdiagnosis after screening mammography among … breast cancer overdiagnosis by comparing cancer incidence among women who discontinued mammography screening … after age 70 compared to women who continued to receive screening mammograms. … years, 47% of women aged 75 to 84 years, and 54% of women aged 85 and older who continue to receive screening
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psnet.ahrq.gov/issue/good-medical-care-can-suffer-late-day
December 16, 2020 - May 14, 2014
Screening for adverse drug events: a randomized trial of automated calls … August 31, 2011
Screening for medication errors using an outlier detection system. … August 10, 2019
WebM&M Cases
Anemia and Delayed Colon … Cancer Diagnosis
August 10, 2019
Missed diagnosis of cancer in primary care
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psnet.ahrq.gov/web-mm/preventable-rash
October 01, 2012 - At a routine visit, screening laboratories were checked. … Third, in order to make the diagnosis, appropriate screening for STDs must be done on a routine basis … We are not provided with information regarding additional STD screening tests (such as for gonorrhea … Related Resources
WebM&M Cases
Anemia and Delayed Colon … Cancer Diagnosis
August 10, 2019
WebM&M Cases
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psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
June 24, 2010 - Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial
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psnet.ahrq.gov/node/49736/psn-pdf
June 01, 2015 - This risk mandates screening of all patients for tuberculosis prior to initiation of therapy. … Screening can take place either by purified protein derivative (PPD) or QuantiFERON-TB Gold testing, … increased risk of melanoma has been reported with anti-TNF
drugs, mandating frequent dermatologic screening … Stool culture, CDI testing, and screening for
ova and parasites should be considered at admission for … initiating anti-TNF therapy, infection must be excluded, a gastroenterologist should be
consulted, and screening
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - include a complete blood count, comprehensive metabolic panel, coagulation studies, and blood typing and screening … Related Resources
WebM&M Cases
Anemia and Delayed Colon … Cancer Diagnosis
August 10, 2019
WebM&M Cases
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psnet.ahrq.gov/periodic-issue/periodic-issue-417
November 29, 2023 - Artificial intelligence-supported screen reading versus standard double reading in the Mammography Screening … trial (MASAI): a clinical safety analysis of a randomised, controlled, non-inferiority, single-blinded, screening … artificial intelligence (AI) to be at least as accurate as radiologists in detecting breast cancer in screening … Artificial intelligence-supported screen reading versus standard double reading in the Mammography Screening … artificial intelligence (AI) to be at least as accurate as radiologists in detecting breast cancer in screening
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psnet.ahrq.gov/node/49503/psn-pdf
February 01, 2006 - //psnet.ahrq.gov/web-mm/workaround-error
The Case
A retired 81-year-old physician with metastatic colon … cancer was admitted to an acute care hospital with
pneumonia and congestive heart failure (CHF).
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psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
April 01, 2008 - Appreciate the value of a high-yield screening neurologic exam in primary care. … This missed diagnosis stemmed from performing an incomplete screening neurologic exam and overlooking … Sample screening neurologic exam for PCPs. … Related Resources
WebM&M Cases
Anemia and Delayed Colon … Cancer Diagnosis
August 10, 2019
WebM&M Cases