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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - retrospect appears to have been misdiagnosed by the ED physician, radiologist, and first pulmonary consultant … Unfortunately, the initial pulmonary consultant in this case apparently did not consider the potential
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psnet.ahrq.gov/node/853981/psn-pdf
September 27, 2023 - orientation and/or recall
memory, even if other cortical functions are preserved.2,3 The psychiatry consultant
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psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
July 08, 2022 - In cases in which capacity is questionable, the provider must enlist the aid of a consultant with expertise … Capacity reflects a spectrum of decision-making ability and providers should enlist the help of a consultant
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - Statewide Telehealth Program Enhances Access to Care,
Improves Outcomes for High-Risk Pregnancies in Rural
Area
June 12, 2020
https://psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-
high-risk
Summary
Formerly known as the Antenatal and Neonatal Guidelines, Education…
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
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psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - delineate precisely how responsibility for care is handed off from the ED to admitting physicians and consultants
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psnet.ahrq.gov/node/853058/psn-pdf
August 30, 2023 - Diagnostic reliability in teledermatology: a systematic
review and a meta-analysis.
August 30, 2023
Bourkas AN, Barone N, Bourkas MEC, et al. Diagnostic reliability in teledermatology: a systematic review
and a meta-analysis. BMJ Open. 2023;13(8):e068207. doi:10.1136/bmjopen-2022-068207.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - In cases in which capacity is questionable,
the provider must enlist the aid of a consultant with expertise … Capacity reflects a spectrum of decision-making ability and providers
should enlist the help of a consultant
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psnet.ahrq.gov/issue/emergency-diagnosis-cancer-and-previous-general-practice-consultations-insights-linked
February 17, 2021 - Study
Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey data.
Citation Text:
Abel GA, Mendonca SC, McPhail S, et al. Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey…
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psnet.ahrq.gov/node/48013/psn-pdf
May 29, 2019 - Economic outcomes associated with safety interventions
by a pharmacist–adjudicated prior authorization consult
service.
May 29, 2019
Jacob S, Britt RB, Bryan WE, et al. Economic Outcomes Associated with Safety Interventions by a
Pharmacist-Adjudicated Prior Authorization Consult Service. J Manag Care Spec Pharm. 2…
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psnet.ahrq.gov/web-mm/forgotten-drip
April 01, 2014 - In reviewing the records, consultants realized that the mannitol infusion had been continued for more
-
psnet.ahrq.gov/node/49577/psn-pdf
January 01, 2009 - communication between the
pump user and hospital staff, including practitioners on the primary team, diabetes consultants
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - Some radiology departments designate a radiologist, fellow, or resident as the consultant of the day
-
psnet.ahrq.gov/node/40658/psn-pdf
August 03, 2011 - Development and validation of a tool to improve
paediatric referral/consultation communication.
August 3, 2011
Stille CJ, Mazor KM, Meterko V, et al. Development and validation of a tool to improve paediatric
referral/consultation communication. BMJ Qual Saf. 2011;20(8):692-7. doi:10.1136/bmjqs.2010.045781.
https:…
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psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
June 02, 2021 - Involving consultants from large-volume urban enters early with complex patients in rural hospitals can
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psnet.ahrq.gov/issue/10-leadership-mindsets-high-reliability-organizations-how-empower-caregivers-and-engage
August 12, 2020 - Newspaper/Magazine Article
10 Leadership mindsets for high reliability organizations. How to empower caregivers and engage patients in patient safety.
Citation Text:
10 Leadership mindsets for high reliability organizations. How to empower caregivers and engage patients in patient safety…
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - SPOTLIGHT CASE
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
Citation Text:
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - Spotlight
Spotlight
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
1
Source and Credits
This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Samantha Brown…
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psnet.ahrq.gov/node/61044/psn-pdf
January 01, 2021 - Seven features of safety in maternity units: a framework
based on multisite ethnography and stakeholder
consultation.
October 21, 2020
Liberati EG, Tarrant C, Willars J, et al. Seven features of safety in maternity units: a framework based on
multisite ethnography and stakeholder consultation. BMJ Qual Saf. 2021;3…
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psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
January 01, 2024 - First-Episode Psychosis and the Role of the Psychiatric Consultant.