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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - SPOTLIGHT CASE
A Weighty Mistake
Citation Text:
Bokser SJ. A Weighty Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/node/73526/psn-pdf
July 28, 2021 - Medication Errors in Retail Pharmacies: Wrong Patient,
Wrong Instructions.
July 28, 2021
Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
The Case
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psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
May 01, 2008 - SPOTLIGHT CASE
A Painful Medication Reconciliation Mishap
Citation Text:
Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/49744/psn-pdf
October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced
Hemolysis in a Patient With a Known Allergy
October 1, 2015
Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known
Allergy. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…
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psnet.ahrq.gov/node/49618/psn-pdf
February 01, 2011 - One Toxic Drug Is Not Like Another
February 1, 2011
Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
Case Objectives
Distinguish between the three distinct regulatory processes of board certification, medical licensure,
and credential…
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …
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psnet.ahrq.gov/node/33720/psn-pdf
November 01, 2011 - In Conversation With… Eduardo Salas, PhD
November 1, 2011
In Conversation With… Eduardo Salas, PhD . PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
Editor's note: Eduardo Salas, PhD, is a University Trustee Chair and Pegasus Professor of Psychology at
the University of Ce…
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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - SPOTLIGHT CASE
Unexplained Apnea Under Anesthesia
Citation Text:
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy
Citation Text:
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - April 3, 2024
Improving diagnosis by improving education: a policy brief on education … September 12, 2018
Competencies for improving diagnosis: an interprofessional framework
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psnet.ahrq.gov/node/74149/psn-pdf
January 07, 2022 - He was ultimately discharged with a diagnosis of “Bipolar 1 – moderate-severe with mixed
features.” … series of all types of diagnostic errors in medicine found that “failure to consider” a
particular diagnosis … We can debate
whether the ultimate diagnosis of bipolar disorder might have been made earlier, the diagnosis … About 54% of individuals who died by suicide in 27 states in 2015 had
not received a clinical diagnosis … https://psnet.ahrq.gov/webmm/submit-case
Periodically, the Primary-Care Research in Diagnosis Errors
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psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
November 16, 2022 - Technology now has a prominent role in many aspects of healthcare delivery including admissions, discharge, diagnosis … used HFE methods and principles to create a clinical decision support (CDS) for pulmonary embolism diagnosis … Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/node/836976/psn-pdf
April 27, 2022 - Compartment syndrome is a clinical diagnosis and patients’ reported symptoms are the earliest indicators … like that
used in pulse oximetry, has been proposed as an objective and non-invasive tool for the diagnosis … tool to monitor for compartment syndrome.30 As in adults, compartment syndrome remains a
clinical diagnosis … Compartment syndrome is a clinical diagnosis. … Acute compartment syndrome in children: contemporary
diagnosis, treatment, and outcome.
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psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - The diagnosis of Cushing syndrome was considered, and subsequent testing for this syndrome was positive
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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - Breast abscess mimicking malignant mass due to retained penrose drain: diagnosis by mammography and MRI
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psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
March 22, 2009 - health literacy has been repeatedly linked to problems with the use of preventive services, delayed diagnoses
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psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
December 14, 2022 - Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
October 01, 2007 - Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
July 01, 2006 - Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
March 01, 2009 - health literacy has been repeatedly linked to problems with the use of preventive services, delayed diagnoses