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psnet.ahrq.gov/node/49545/psn-pdf
September 01, 2007 - Whatever its cause, the diagnosis of retroperitoneal hematoma is initially
made on clinical grounds. … CT scanning can be used to confirm the diagnosis.
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psnet.ahrq.gov/node/49643/psn-pdf
December 01, 2011 - Once the diagnosis was established, she was started on plasmapheresis using a Quinton
catheter placed … At the time that the diagnosis was made, the Medical Director of Case Management contacted the
neurologist
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - to appointments Issues such as lack of access to transportation may lead to missed care or delayed diagnoses … cards, which had the patient’s name and their date of birth, and then it was a line with a date, a diagnosis … the top of the card the person’s date of birth and their name, and then each line was a visit with a diagnosis … was allergic to penicillin, we don’t know if the patient got better, we don’t know on what basis the diagnosis … was made, we don’t know if it was the correct diagnosis.
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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - 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/what-happened-telemetry
January 18, 2012 - June 11, 2014
WebM&M Cases
Delay in Malignancy Diagnosis … September 24, 2016
Reducing the risk of delayed colorectal cancer diagnoses through an
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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal
pain, fevers, and short…
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psnet.ahrq.gov/node/846935/psn-pdf
March 29, 2023 - Maternal Safety and Perinatal Mental Health
March 29, 2023
Allen C, Van CM, Mossburg S. Maternal Safety and Perinatal Mental Health . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
Maternal patient safety is a critical aspect of healthcare given the complex pr…
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - Medication Overdose
Citation Text:
Kaushal R. Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/node/49447/psn-pdf
June 01, 2004 - Dangerous Dapsone
June 1, 2004
Bookwalter T. Dangerous Dapsone. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/dangerous-dapsone
The Case
A 78-year-old woman with newly diagnosed multiple myeloma on corticosteroids presented to the
emergency department with dyspnea. Upon admission, she was found to be hypo…
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psnet.ahrq.gov/web-mm/wrong-route-nutrients
September 04, 2010 - Wrong Route for Nutrients
Citation Text:
Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/49802/psn-pdf
August 01, 2017 - Add-on Case and the Missing Checklist
August 1, 2017
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
The Case
A 65-year-old woman was admitted for evaluation of abdominal pain and weight loss. Based on diagnostic
data and ima…
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psnet.ahrq.gov/web-mm/one-ace-too-many
June 21, 2016 - One ACE Too Many
Citation Text:
Juurlink DN. One ACE Too Many. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
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…
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psnet.ahrq.gov/perspective/overuse-patient-safety-problem
September 01, 2014 - Medical care may cause harm directly via complications of treatments or indirectly by generating excess diagnoses … The dreaded thought of missing a cancer diagnosis leads to overtesting. … WebM&M Cases
A Costly Colonoscopy Leads to a Delay in Diagnosis
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psnet.ahrq.gov/web-mm/getting-root-matter
September 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/web-mm/silent-pain-neck
August 19, 2020 - Diagnosis of a neck hematoma can be particularly challenging after anterior cervical spine surgery due … December 14, 2022
WebM&M Cases
Delayed Diagnosis … Complications
February 23, 2022
WebM&M Cases
Delayed Diagnosis
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psnet.ahrq.gov/node/857059/psn-pdf
November 29, 2023 - 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 with
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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - The resident physician's diagnosis was a "viral syndrome" causing the diarrhea and low-grade fever. … diagnostic testing.( 8–10 ) While none of these studies addressed specific patient outcomes (e.g., delays in diagnosis … WebM&M Cases
Endometriosis: A Common and Commonly Missed and Delayed Diagnosis
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - to appointments Issues such as lack of access to transportation may lead to missed care or delayed diagnoses
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psnet.ahrq.gov/web-mm/privacy-or-safety
December 01, 2011 - particularly when the information being shared is considered to be particularly sensitive (e.g., mental health diagnoses