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psnet.ahrq.gov/node/49565/psn-pdf
July 01, 2008 - Wrong Route for Nutrients
July 1, 2008
Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wrong-route-nutrients
The Case
An 82-year-old man living in a skilled nursing facility (SNF) had not been eating or drinking well for about 6
months. He had lost weight and d…
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psnet.ahrq.gov/web-mm/polypharmacy
March 01, 2007 - Polypharmacy
Citation Text:
Guglielmo JB. Polypharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
July 01, 2011 - Spotlight Case July 2008
Spotlight Case
Watch the Warfarin!
1
2
Source and Credits
This presentation is based on the July 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Raman Khanna, MD, and Margaret Fang, MD, MPH; University of California, Sa…
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psnet.ahrq.gov/node/73905/psn-pdf
October 06, 2021 - Health Equity and Maternal Health
October 6, 2021
Tully K, Stuebe AM, Gibson A, et al. Health Equity and Maternal Health. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/health-equity-and-maternal-health
Redefining Maternal Safety
Maternal safety refers to the safety of a person during pregnancy, childb…
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psnet.ahrq.gov/node/49509/psn-pdf
April 01, 2006 - Insert Omission
April 1, 2006
Darney P. Insert Omission. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/insert-omission
The Case
A multiparous woman presented to the gynecology clinic requesting intrauterine contraceptive (IUC)
placement (Figure). She was appropriately counseled on the risks and benefits o…
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psnet.ahrq.gov/node/49413/psn-pdf
September 01, 2003 - Retained surgical sponge: diagnosis with CT and
sonography.
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psnet.ahrq.gov/node/49542/psn-pdf
August 21, 2007 - This preceded her ovarian cancer diagnosis by several
years, and she was treated with 6 months of warfarin
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psnet.ahrq.gov/node/49617/psn-pdf
January 01, 2011 - urinary biomarkers (e.g., KIM-1) that are more specific and sensitive than Scr may result in
earlier diagnosis
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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
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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
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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
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psnet.ahrq.gov/web-mm/copy-and-paste
December 10, 2014 - This preceded her ovarian cancer diagnosis by several years, and she was treated with 6 months of warfarin
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psnet.ahrq.gov/node/73549/psn-pdf
July 28, 2021 - It also highlights that the correct diagnosis and treatment of LAST in the operating
room is critically … these important discussions did not
take place in this case, although the anesthesiologist’s rapid diagnosis
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psnet.ahrq.gov/node/836840/psn-pdf
April 22, 2021 - treatment
or procedure.2 Among patients who are diagnosed with VTE, the mortality rate one month after diagnosis … part I: epidemiology, risk factors and risk
stratification, pathophysiology, clinical presentation, diagnosis
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psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
June 19, 2024 - treatment or procedure. 2 Among patients who are diagnosed with VTE, the mortality rate one month after diagnosis … part I: epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis
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psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - Complications of ECMO During Transport
April 29, 2020
Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
The Case
A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with
acute on chro…
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psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
November 25, 2020 - Had the necessary resources been available when she first presented, diagnosis and treatment would have … November 25, 2020
WebM&M Cases
Delay in Appropriate Diagnosis … WebM&M Cases
Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis … 14, 2023
WebM&M Cases
Under Pressure: Delayed Diagnosis
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psnet.ahrq.gov/node/49564/psn-pdf
July 01, 2008 - Physical dependence on an opioid is just one of the seven criteria
for the diagnosis of opioid dependence … objective measure was not used in this case, but given the constellation of symptoms, a presumptive
diagnosis … Even when this
diagnosis is strongly suspected, a full and complete history and physical examination … In the patient in this case, the overt abdominal pain would lead me to consider other diagnoses. … His nontender abdominal examination also would be consistent with this diagnosis.
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psnet.ahrq.gov/web-mm/e-prescribing-e-error
February 03, 2021 - systems have a more difficult time addressing certain safety issues, such as wrong patient or wrong diagnosis … Sharing such summaries can alert the pharmacist to treatments without appropriate diagnoses, as well
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psnet.ahrq.gov/web-mm/did-we-forget-something
April 28, 2021 - Retained surgical sponge: diagnosis with CT and sonography.