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psnet.ahrq.gov/web-mm/forgotten-radiographic-read
June 07, 2016 - October 7, 2011
Medical misdiagnoses can have fatal consequences.
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psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - culture where physicians are not punished
for isolated lapses or systems failures, but face clear consequences
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psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
October 27, 2021 - WebM&M Cases
To Dilute or Not Dilute: Drug Errors and Consequences
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psnet.ahrq.gov/web-mm/bloody-bp-cuff
June 21, 2016 - problems of profiling and stigma, these “eyeball tests” proved highly inaccurate, sometimes with serious consequences
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psnet.ahrq.gov/node/49817/psn-pdf
January 01, 2018 - The extent and importance of
unintended consequences related to computerized provider order entry.
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - Although it was unclear whether the delayed notification had adverse clinical consequences (the role
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psnet.ahrq.gov/web-mm/say-it-again
January 31, 2020 - " can be short-lived if the interdependencies among information needs, communication processes, and consequences
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - Although drug shortages can have direct consequences—such as when a critical medication is unavailable
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psnet.ahrq.gov/web-mm/raise-bar
May 29, 2024 - WebM&M Cases
To Dilute or Not Dilute: Drug Errors and Consequences
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psnet.ahrq.gov/web-mm/lethal-vertigo
September 20, 2011 - COVID-19 and the Built Environment
June 30, 2021
Anticipated consequences
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psnet.ahrq.gov/node/73229/psn-pdf
May 26, 2021 - The
consequences of repeatedly receiving toxic doses of norepinephrine likely contributed to the sequelae
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psnet.ahrq.gov/web-mm/missing-trauma
March 03, 2011 - In adults, failure to diagnosis such injuries early carries dire clinical consequences with significant
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psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
April 24, 2024 - Documentation of a normal EKG in the wrong chart may have unintended consequences as well.
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psnet.ahrq.gov/web-mm/air-side-caution
April 21, 2015 - December 21, 2022
Evaluation of medium-term consequences of implementing commercial computerized
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psnet.ahrq.gov/node/49653/psn-pdf
May 01, 2012 - thrombotic
complications.(1) In the past, such complications were often considered to be inevitable consequences
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psnet.ahrq.gov/node/49569/psn-pdf
September 01, 2008 - The pediatric patient in this case did not experience any long-term consequences, but the feeding tube
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psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
December 22, 2018 - Ischemia
August 31, 2022
WebM&M Cases
The Consequences
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psnet.ahrq.gov/node/49459/psn-pdf
September 01, 2004 - for understanding whether a given intervention will work, in what
contexts, and with what unintended consequences
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psnet.ahrq.gov/node/49625/psn-pdf
May 01, 2011 - Accidental misconnection
between incompatible systems has been known for years, with sometimes fatal consequences
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
August 01, 2014 - most severe SSTI and the diagnosis is often missed or delayed
Delay in diagnosis can have devastating consequences