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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - SPOTLIGHT CASE
Signout Fallout
Citation Text:
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
August 20, 2018 - Failed Interpretation of Screening Tool: Delayed Treatment
Citation Text:
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. 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/conversation-lucian-leape-md
June 12, 2019 - One sad thing about patient safety is the consequences are borne almost entirely by the patient.
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psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
February 26, 2025 - What the Journal did not allow us to publish was the cost consequences of massively reducing our postoperative
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psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - 12.3%), all of which were considered minor complications that did not result in significant clinical consequences
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psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - Fatigue on the flight deck: the consequences of sleep loss and the benefits of napping.
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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
December 01, 2017 - ongoing assessment of procedural skills, along with easy access to peer coaching.( 12 ) There should be consequences
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psnet.ahrq.gov/perspective/conversation-leah-binder-ma-mga
February 26, 2025 - care is that these things are often nuanced and the science is imperfect and there are unanticipated consequences
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psnet.ahrq.gov/node/865655/psn-pdf
April 24, 2024 - compartment syndrome].”2
Although the ultimate decision rests with the patient, most experts agree that the consequences
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psnet.ahrq.gov/node/853902/psn-pdf
September 27, 2023 - psnet.ahrq.gov//#1
https://psnet.ahrq.gov/issue/cognitive-errors-diagnosis-instantiation-classification-and-consequences
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psnet.ahrq.gov/node/73906/psn-pdf
October 06, 2021 - think about all the different things that possibly could go wrong with the care and the resultant
consequences
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psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - had an ideal response of counseling breastfeeding mothers who requested infant formula about possible consequences
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - When an RSI is suspected, the clinical team must carefully consider the potential consequences of not
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - Fatigue on the flight deck: the consequences of sleep loss and the benefits of napping.
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Consequences and complications of peritoneal adhesions. Colorectal Dis. 2007;9 Suppl
2:25-34.
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - When enough of these holes or weaknesses align, it can lead to devastating consequences, such as in the
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - November 16, 2022
WebM&M Cases
The Consequences
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - Consequences and complications of peritoneal adhesions.
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psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
May 28, 2020 - implantable, life-saving devices. [1] Ineffective or unsafe medical devices can have detrimental consequences
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - Diagnosing a Stroke
June 1, 2018
WebM&M Cases
Consequences