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psnet.ahrq.gov/node/73104/psn-pdf
January 04, 2021 - , developers need to proactively develop comprehensive mitigation strategies to
address unintended consequences … invest in research and evaluation that will enable this purposeful learning risks
repeating the tragic consequences
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - supplements for a patient on furosemide is routine, however, this same
drug may lead to life-threatening consequences … Numerous barriers to reporting exist including fear of
consequences, a culture of blame, perception
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psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
May 01, 2013 - )
WebM&M Cases
Getting a Good Report Card: Unintended Consequences
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psnet.ahrq.gov/psnet-collection?search=%7B%22Topic%22%3A%22COVID-19%22%7D&f%5B0%5D=clinical_area%3A5356
October 27, 2021 - All Content
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psnet.ahrq.gov/web-mm/inflicting-confusion
August 04, 2021 - Inflicting Confusion
Citation Text:
Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/pathologic-mistake
February 15, 2010 - Pathologic Mistake
Citation Text:
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/web-mm/no-bp-during-nibp
March 01, 2011 - No BP During NIBP
Citation Text:
Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
September 01, 2012 - Add-on Case and the Missing Checklist
Citation Text:
Catchpole K. Add-on Case and the Missing Checklist. 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/dont-push
March 02, 2011 - Don't Push
Citation Text:
Meltzer HY. Don't Push. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
May 01, 2017 - Wrong Turn through Colon: Misplaced PEG
Citation Text:
Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary …
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psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - SPOTLIGHT CASE
Two Wrongs Don't Make a Right (Kidney)
Citation Text:
DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - CYP450 Drugs: Expect the Unexpected
Citation Text:
Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - Failed Interpretation of Screening Tool: Delayed
Treatment
September 1, 2017
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
The Case
An 88-year-old man present…
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psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
February 01, 2010 - increase in handoffs that comes with duty hour restrictions, has been one of the most striking unintended consequences
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psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
August 01, 2005 - If mandates can be implemented without major unintended consequences that adversely affect access and
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psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - but is also associated with harms (e.g., radiation exposure, false-positive results , psychological consequences
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psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
January 17, 2018 - The consequences of excessive reliance on diagnostic tests to convey information that should have been
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psnet.ahrq.gov/node/49624/psn-pdf
May 01, 2011 - occurred; do not speculate
• Tell the patient whether the adverse event was preventable
What are the consequences
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psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
September 25, 2019 - Errors in pathology and laboratory medicine: consequences and prevention.