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3181. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis | PSNet
      psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
      January 13, 2010 - January 13, 2010 WebM&M Cases Delayed Diagnosis in the … Examination March 31, 2021 WebM&M Cases Timely diagnosis … April 10, 2024 WebM&M Cases Delay in Malignancy Diagnosis … Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses

3182. Misplaced Nasogastric Tube Resulting in Aspiration | PSNet
      psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
      August 01, 2009 - Evaluating a mobile application for improving clinical laboratory test ordering and diagnosis … View More Related Resources Interventions to improve timely cancer diagnosis … Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses … WebM&M Cases Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis

3183. Dangerous Shift | PSNet
      psnet.ahrq.gov/web-mm/dangerous-shift
      July 24, 2013 - attentional resources during the update based on patient instability and level of uncertainty around a diagnosis … Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses

3184. Crossing the Line | PSNet
      psnet.ahrq.gov/web-mm/crossing-line
      December 01, 2012 - Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses … WebM&M Cases Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis

3185. The Missing Abscess: Radiology Reads in the Digital Era | PSNet
      psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
      January 01, 2009 - specifically what the study is expected to evaluate; (iii) the relevant surgical procedures and patient diagnoses … Related Resources WebM&M Cases Delay in Malignancy Diagnosis

3186. The ECG Is Not Normal | PSNet
      psnet.ahrq.gov/web-mm/ecg-not-normal
      November 10, 2015 - wife when she complained of pain shortly after suffering an apparent miscarriage, coming up with no diagnosis … They may leap to diagnoses, either in their own field of expertise or far afield.

3187. Safety in Radiology | PSNet
      psnet.ahrq.gov/perspective/safety-radiology
      October 01, 2013 - In fact, multidetector row CT technology and advanced protocols have revolutionized the diagnosis and … imaging is to adhere to the ALARA principle while ensuring that information is sufficient for accurate diagnoses … large number of CTs, but also the way we were doing them was leading to higher doses than needed for diagnosis … the doses used, there is no value to anyone in using doses that are higher than needed for medical diagnosis … buying this equipment and using these newer fancy protocols when in fact they may not even help with diagnosis

3188. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867429/psn-pdf
      December 18, 2024 - [Available at] Diagnosis  MRI Diagnosis is confirmed via spinal MRI with history and physical examination … ineffective communication or diffusion of responsibility among team members, or “anchor” on a single diagnosis … errors-managing-open-wound-elbow-leading-multiple-complications-and-operations https://psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture

3189. Tacit Handover, Overt Mishap | PSNet
      psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
      August 01, 2006 - for Patient Safety Research December 1, 2003 Antecedent treat-and-release diagnoses

3190. In Conversation With… Erik Hollnagel, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
      February 26, 2025 - Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses

3191. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49780/psn-pdf
      January 01, 2017 - specifically what the study is expected to evaluate; (iii) the relevant surgical procedures and patient diagnoses

3192. Communication Failure—Who's in Charge? | PSNet
      psnet.ahrq.gov/web-mm/communication-failure-whos-charge
      April 01, 2018 - compared with those cared for in multidisciplinary PICUs, with the exception of a few specific cardiac diagnoses

3193. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49513/psn-pdf
      July 01, 2006 - Focus initial efforts on the most frequent source units and patient types (ages, clinical diagnoses).

3194. Medication Mix-Up Leads to Patient Death | PSNet
      psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
      July 08, 2022 - safety indicators in 15 OECD member countries: a methodological approach of adjustment by secondary diagnoses

3195. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866343/psn-pdf
      December 31, 2024 - After these results, the working diagnosis changed to acute heart failure exacerbation and the patient … Syncope is a common ED presentation with a broad differential diagnosis that includes multiple potential … should consider implementing policies and procedures that direct patients with high-risk admitting diagnoses

3196. Translating From Normal to Abnormal | PSNet
      psnet.ahrq.gov/web-mm/translating-normal-abnormal
      October 02, 2019 - Miscommunications from poor translation can lead to delayed diagnoses and treatment, causing injury and … October 28, 2016 How timely is diagnosis of lung cancer? … November 1, 2016 WebM&M Cases A "Reflexive" Diagnosis

3197. Triple Handoff | PSNet
      psnet.ahrq.gov/web-mm/triple-handoff
      March 01, 2004 - In this case, important information was lost due to handoffs, causing diagnosis and treatment delay and … New information includes a brief history and diagnosis, updated medications and problem list, current … Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses

3198. Specimen Almost Lost | PSNet
      psnet.ahrq.gov/web-mm/specimen-almost-lost
      September 21, 2022 - If tests need to be redrawn or repeated, the resulting delay in diagnosis may cause a delay in treatment … a worrisome gastrointestinal polyp, loss of the specimen results may lead to an inability to make a diagnosis … How confident is the treating clinician of the clinical diagnosis in the absence of a definitive pathologic … diagnosis? … April 24, 2018 WebM&M Cases Delayed Diagnosis of Endocrinologic

3199. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.173_slideshow.ppt
      April 01, 2008 - Examination of the bowel showed Aspergillus, leading to a diagnosis of disseminated Aspergillosis.

3200. Artificial Intelligence and Patient Safety: Promise and Challenges | PSNet
      psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
      March 27, 2024 - For example, during patient examinations and EHR documentation, the AI system can suggest diagnoses or … Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses