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psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
November 08, 2013 - conclusions to focus on how defective system design prevented his colleagues from making the appropriate diagnoses … Thrombosis
June 28, 2023
WebM&M Cases
Delayed Diagnosis
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psnet.ahrq.gov/web-mm/discharge-against-medical-advice
July 01, 2017 - care physician, admission through the emergency department, admission with a substance abuse–related diagnosis … Communication Provide the patient with a brief written summary of his or her diagnoses
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psnet.ahrq.gov/web-mm/electronic-err
April 01, 2014 - In one study, 40% of encounters had no diagnosis recorded and 30% had no therapeutic agent recorded.( … Secondary to Medication Access Issue
April 1, 2014
Evaluation and accurate diagnoses
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psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
November 27, 2019 - dysregulation) based on the initial presentation (spinal cord injury), thereby overlooking other possible diagnoses … Premature Closure: Anchoring Bias, Occam’s Error, Availability Bias, Search Satisficing, Yin-Yang Error, Diagnosis
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.287_slideshow.ppt
December 01, 2012 - Assessment, diagnosis, and management. … Non-surgical Biopsy
Non-surgical biopsy is less invasive than surgical diagnosis
Can be performed via … Endobronchial ultrasound for the diagnosis and staging of lung cancer. … Ann Intern Med. 2011;155:137-144. http://www.ncbi.nlm.nih.gov/pubmed/21810706
Surgical Diagnosis … Surgical diagnosis is often preferred for nodules that are very likely to be cancerous
The surgery
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
May 01, 2009 - Confusion Assessment Method
Diagnosis of delirium requires features 1 and 2, and either 3 or 4
See … contribute to delirium and expose patients to safety risk
Family members and caregivers are crucial to the diagnosis
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psnet.ahrq.gov/web-mm/discharge-fumbles
September 09, 2009 - With respect to patient factors, longer lengths of stay, a diagnosis of diabetes mellitus, and more medications … Often, summaries lack important information describing the most responsible diagnosis, the results of … vulnerable patients—such as those on high-risk or large numbers of medications, and patients with multiple diagnoses … to these questions BEFORE you leave Do you understand why you were hospitalized, what your diagnosis
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psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
November 04, 2015 - Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/node/33618/psn-pdf
September 01, 2005 - The cognitive psychology of missed diagnoses.
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - conclusions to focus on how defective system design prevented his
colleagues from making the appropriate diagnoses
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psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-reducing-inpatient-harm
February 26, 2025 - Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
February 26, 2025 - Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - Hospital-acquired hypoglycemia is also on the list of Medicare's new "no pay for errors" diagnoses.
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psnet.ahrq.gov/perspective/conversation-eric-j-topol-md
February 26, 2025 - power shifts to patients, my guess is that the same companies that are coming up with algorithms for diagnosis … willing—and the vast majority are—then these resources can be helpful for individuals with that same diagnosis
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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - historian; he was alert and oriented to person and place but could not recall his prostate cancer
diagnosis … She knew of his cancer diagnosis
but was unsure why he was not receiving treatment. … In this particular case,
the patient exhibited knowledge of his cancer diagnosis and expressed interest … his situation and could not offer a
rationale for his decisions, likely secondary to his childhood diagnosis … on providing patient with relief from symptoms, pain, and stress of serious illness –
no matter the diagnosis
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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - historian; he was alert and
oriented to person and place but could not recall his prostate
cancer diagnosis … She knew of his cancer diagnosis but was unsure
why he was not receiving treatment. … • In this particular case, the patient exhibited knowledge of his cancer
diagnosis and expressed … his situation and could not offer a rationale
for his decisions, likely secondary to his childhood diagnosis … on providing patient with relief from symptoms, pain, and
stress of serious illness – no matter the diagnosis
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psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - The ED reported these findings to the hospitalist who admitted the patient with a
presumed diagnosis … For cardiac ultrasound,
emergency medicine providers can accurately make diagnoses (when compared to … Anchoring bias played a role in the decision to treat the patient for fluid overload—a diagnosis
that … Emergency physician focused cardiac ultrasound improves diagnosis of
ascending aortic dissection. … Thrombosis of prosthetic heart valves: diagnosis and therapeutic
considerations.
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psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
August 21, 2005 - formulation; description of the reaction; indication for the drug being taken (if there is no clinical diagnosis … Diagnosis of true drug allergy is challenging and patients have often had adverse drug reactions recorded … Drug allergy: diagnosis and management of drug allergy in adults, children and young people. … 2022
WebM&M Cases
Correct Treatment Plan for Incorrect Diagnosis
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psnet.ahrq.gov/node/73300/psn-pdf
July 01, 2022 - of the program found that it significantly increased patients'
understanding and knowledge of their diagnoses … Many patients lack understanding of their hospitalization diagnosis
and treatment plans,9 resulting … factors for readmission (8Ps)
include (1) problems with medications, (2) psychological, (3) principal diagnosis