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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - issues were (1) the original complication of a malpositioned transhepatic PEG tube, which was a delayed diagnosis … complications may be underreported due to the lack of specific symptoms and the need for imaging for diagnosis … Delayed or missed diagnoses comprise the most common and costly reasons for malpractice claims, 28
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psnet.ahrq.gov/node/49611/psn-pdf
October 01, 2010 - reporting suicidality after controlling for confounding factors (demographics, depressive symptoms, and
diagnoses … Hopelessness, depression, suicidal ideation, and clinical
diagnosis of depression.
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - If the use, diagnosis, and patient type align with what the CDS has been programmed to identify as appropriate … Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - insistence that the infant's breastfeeding difficulties be addressed ultimately led to the correct
diagnosis … neurological, etc.).(9)
Ultimately, the in-person assessment was crucial to coming to the correct diagnosis … Lactation specialists
recognize tongue-tie as a cause of breastfeeding difficulties.(11) The diagnosis … ankyloglossia ranges from 1 in 20 to 1 in 500, and a fair amount of suspicion is required in
making the diagnosis … knowledge of the benefits of breastfeeding and her persistence ultimately allowed for the correct
diagnosis
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psnet.ahrq.gov/web-mm/failure-reevaluate
February 01, 2014 - 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/node/49641/psn-pdf
November 01, 2011 - The patient had no knowledge of her hepatitis B diagnosis.
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psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
June 01, 2018 - November 8, 2023
Does a suggested diagnosis in a general practitioners' referral question
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psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education
January 31, 2020 - focused on establishing an understanding of body systems and the technical processes associated with diagnosis … Colleges and Nursing Quality and Safety Education for Nurses , World Health Organization (WHO) , and diagnosis
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psnet.ahrq.gov/node/49417/psn-pdf
October 01, 2003 - of unprotected intercourse during the 6
months during which she was seropositive but unaware of her diagnosis … If the former, the lab treats the
result as it would any new diagnosis of HIV and contacts the responsible
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - of unprotected intercourse during the 6 months during which she was seropositive but unaware of her diagnosis … If the former, the lab treats the result as it would any new diagnosis of HIV and contacts the responsible
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psnet.ahrq.gov/web-mm/its-all-syringe
February 01, 2013 - May 1, 2005
WebM&M Cases
Delayed Breast Cancer Diagnosis … January 6, 2017
Process of care failures in breast cancer diagnosis.
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psnet.ahrq.gov/web-mm/deadly-duo
April 28, 2021 - reporting suicidality after controlling for confounding factors (demographics, depressive symptoms, and diagnoses … Hopelessness, depression, suicidal ideation, and clinical diagnosis of depression. … Dialysis
April 28, 2021
WebM&M Cases
Delayed Diagnosis
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psnet.ahrq.gov/node/72613/psn-pdf
December 22, 2020 - able to push through is that in dentistry there was no standardized, accepted
terminology for dental diagnoses … That is not to say a diagnosis is not made by the provider, it is just
not recorded in a structured … As
such, the diagnosis may only be recorded in the note in an unstructured manner.
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Gathering Data
Once established, the RCA team generates a differential diagnosis for systems factors … with a reduction in medication errors.(13) Finally,
trainees should be taught that the differential diagnosis … In addition, smart systems could include admitting
diagnoses and, by combining that with patient location
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psnet.ahrq.gov/node/49538/psn-pdf
June 01, 2007 - While her diagnosis was likely hastened through her participation in
the research study (as she expressed
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psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
February 01, 2019 - WebM&M Cases
Correct Treatment Plan for Incorrect Diagnosis
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psnet.ahrq.gov/node/840175/psn-pdf
November 16, 2022 - It is important to recognize at the start that the differential diagnosis of peripheral arterial emboli … https://psnet.ahrq.gov//#3
Diagnosis of acute limb ischemia in a lower extremity is based on the patient
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
View more articles from the same authors.
Citation Text:
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
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psnet.ahrq.gov/node/33834/psn-pdf
May 22, 2017 - Opioid Overdose as a Patient Safety Problem
May 22, 2017
Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
Perspective
Opioids serve a valuable role in the treatment of acute pain and pain associat…
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psnet.ahrq.gov/node/49745/psn-pdf
October 01, 2015 - Amphotericin Toxicity
October 1, 2015
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/amphotericin-toxicity
The Case
A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral
posaconazole for residual fungal disease. She present…