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psnet.ahrq.gov/web-mm/amphotericin-toxicity
April 01, 2014 - Amphotericin Toxicity
Citation Text:
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49554/psn-pdf
January 01, 2008 - Chemotherapy Extravasation
January 1, 2008
Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/chemotherapy-extravasation
The Case
A 73-year-old woman with no past medical history was diagnosed with stage IIIA breast cancer. She and
her oncologist decided to begin sys…
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psnet.ahrq.gov/node/49426/psn-pdf
November 01, 2003 - Don't Push
November 1, 2003
Meltzer HY. Don't Push. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dont-push
The Case
A 37-year-old HIV-positive woman was brought to the emergency room by her family because she had
exhibited altered mentation for 3 days. The patient had been diagnosed with HIV infection 3 …
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psnet.ahrq.gov/node/49462/psn-pdf
October 01, 2004 - Thin Air
October 1, 2004
Gaba DM. Thin Air. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/thin-air
Case Objectives
Identify the gas-specific non-interchangeable connectors used for bulk gas supply outlets in
hospitals.
Define forcing function, both in engineered safety devices and in human procedures.
R…
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psnet.ahrq.gov/node/836978/psn-pdf
May 16, 2022 - Check Twice, Transport Once
May 16, 2022
DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/check-twice-transport-once
The Case
Case #1: A 26-year-old woman (Patient A) presented to the Emergency Department (ED) with abdominal
pain and was diagnosed with “s…
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psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - July Syndrome
June 1, 2016
Young JQ. July Syndrome. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/july-syndrome
The Case
A 64-year-old man was seen in the thoracic surgery clinic in June after being diagnosed with a right lower
lobe lung cancer. The attending surgeon saw the patient along with his fellow,…
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
May 14, 2020 - With a robust telehealth infrastructure in place, patients may receive more timely diagnoses and treatment
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psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
November 16, 2022 - Diagnosis and treatment of Aspergillus flavus sternal wound infections after cardiac surgery. … October 19, 2022
WebM&M Cases
Diagnosing a Missed Diagnosis
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psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
May 14, 2020 - With a robust telehealth infrastructure in place, patients may receive more timely diagnoses and treatment
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psnet.ahrq.gov/web-mm/forgotten-radiographic-read
June 07, 2016 - The reviews concluded that the delay in diagnosis of internal mesenteric artery dissection and bowel … dedicated radiologist read all images the following workday ultimately led to this patient's correct diagnosis
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psnet.ahrq.gov/node/72689/psn-pdf
January 29, 2021 - with
careful dental care, including salt and sodium bicarbonate mouthwash and pain control.4 A timely diagnosis … A guide to utilization of the microbiology laboratory for
diagnosis of infectious diseases: 2013 recommendations
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psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
September 27, 2023 - laboratory and other assessments; and to allow further clinical observation to make a more precise diagnosis … March 29, 2023
WebM&M Cases
Delayed Diagnosis and
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psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-postdischarge-needs
March 27, 2024 - Program adopters report more than 20 different approaches; these range from picking three diagnoses currently
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psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
September 01, 2005 - The cognitive psychology of missed diagnoses.
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - examinations are not well understood, but it is a disservice to female patients and may contribute to
missed diagnoses
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psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
March 27, 2024 - July 13, 2009
Missed diagnoses of acute cardiac ischemia in the emergency department.
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psnet.ahrq.gov/node/33789/psn-pdf
August 01, 2015 - to the patient about the things that the physician uniquely can
do—complicated decisions, complex diagnoses
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/node/60363/psn-pdf
March 01, 2021 - Program adopters report more than 20 different
approaches; these range from picking three diagnoses