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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - a procedure (gastric bypass surgery), aimed at treating a chronic health condition (obesity and its consequences
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psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - As illustrated in this case, mobile device use in hospitals can also have risks and negative consequences
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psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
January 01, 2014 - April 12, 2023
Potential unintended consequences due to Medicare's "No Pay for Errors
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psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
August 01, 2005 - If mandates can be implemented without major unintended consequences that adversely affect access and
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psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - WebM&M Cases
To Dilute or Not Dilute: Drug Errors and Consequences
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psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - Respiratory Depression (2)
• PCA can result in critical respiratory depression events with
significant consequences
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psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - Clinical consequences of misinterpretations of
neuroradiologic CT scans by on-call radiology residents
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - Failure to do so can lead to
tracheal and surrounding structure damage with severe clinical consequences
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psnet.ahrq.gov/node/49807/psn-pdf
October 01, 2017 - case above illustrates, poor translations can lead to miscommunication, which can result in
adverse consequences
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psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - appreciate the
importance of physiologic insulin replacement in patients with type 1 diabetes, and the consequences
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
January 01, 2023 - Predictors and consequences of hematoma after thyroidectomy: an American College of Surgeons National
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psnet.ahrq.gov/node/836885/psn-pdf
May 16, 2022 - Root causes may include not formulating a plan that anticipates potential consequences,
communication
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psnet.ahrq.gov/node/49474/psn-pdf
March 01, 2005 - Due to the high
prevalence of obesity in the United States and its negative health consequences, understanding
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psnet.ahrq.gov/node/865412/psn-pdf
March 27, 2024 - follow-up on abnormal laboratory results is not an uncommon system or process error and can
lead to dire consequences
-
psnet.ahrq.gov/node/49684/psn-pdf
May 01, 2013 - attending oncologist
discussed this with the patient and he was discharged later that day with no adverse consequences
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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - Without these efforts, more serious consequences might have resulted.
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - have been identified as common and universal and secondary to systemic factors that bring undesirable consequences
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psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - able to:
Recognize common and serious pitfalls in diagnosis of Strongyloides and potential consequences
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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - WebM&M Cases
To Dilute or Not Dilute: Drug Errors and Consequences
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - error clearly, support the patient and family, and assist the medical team to prevent long-term adverse consequences