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5581. Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle | PSNet
      psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
      July 23, 2024 - Yamaguchi et al. observed that using radiofrequency identification technologies and novel computer-aided diagnosis … Novel computer-aided diagnosis software for the prevention of retained surgical items.

5582. An Incomplete Anesthesia History Leads to Adverse Outcomes | PSNet
      psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
      January 29, 2021 - inadvertent TMJ dislocation is suspected during the procedure, an X-ray should be taken to confirm the diagnosis … A cholinesterase plasma phenotype test can confirm this diagnosis. 15 The paralysis in Case 1 could

5583. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47448/psn-pdf
      October 10, 2018 - Ten principles for more conservative, care-full diagnosis. … Ten Principles for More Conservative, Care-Full Diagnosis. … https://psnet.ahrq.gov/issue/ten-principles-more-conservative-care-full-diagnosis Safe diagnosis is … multidisciplinary panel to build a 10-element framework outlining steps that support conservative diagnosis … https://psnet.ahrq.gov/issue/ten-principles-more-conservative-care-full-diagnosis https://psnet.ahrq.gov

5584. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35976/psn-pdf
      August 10, 2010 - Guidelines for prevention, diagnosis and treatment of ventilator-associated pneumonia (VAP) in the trauma … Guidelines for prevention, diagnosis and treatment of ventilator- associated pneumonia (VAP) in the … https://psnet.ahrq.gov/issue/guidelines-prevention-diagnosis-and-treatment-ventilator-associated- pneumonia-vap-trauma … investigators used existing data and guidelines to develop this standard operating procedure for the diagnosis … https://psnet.ahrq.gov/issue/guidelines-prevention-diagnosis-and-treatment-ventilator-associated-pneumonia-vap-trauma

5585. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39712/psn-pdf
      July 02, 2014 - Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis. … Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis. … psnet.ahrq.gov/issue/swapping-horses-midstream-factors-related-physicians-changing-their-minds- about-diagnosis … psnet.ahrq.gov/issue/swapping-horses-midstream-factors-related-physicians-changing-their-minds-about-diagnosis … psnet.ahrq.gov/issue/swapping-horses-midstream-factors-related-physicians-changing-their-minds-about-diagnosis

5586. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33828/psn-pdf
      March 01, 2017 - have nothing to do with error but to do with, for example, how we do better prognostication, better diagnosis … The diagnosis agenda is interesting because it may have very little to do with error but instead optimizing

5587. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33826/psn-pdf
      February 01, 2017 - In sum, your first, spontaneous causal diagnosis of the problem's cause is likely to be wrong, and doubling … down on that diagnosis is almost certainly unhelpful, not to mention ineffective.

5588. In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO | PSNet
      psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
      January 12, 2022 - there were notable patient safety concerns associated with factors such as disease exposure, timely diagnosis … failure in patients with COVID-19 and sepsis requires them to be managed differently . 13 , 14 Timely diagnosis … demonstrated to decrease inpatient mortality for patients with sepsis, 16 but the need to confirm a COVID-19 diagnosis

5589. In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0 | PSNet
      psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
      February 28, 2024 - Diagnostic errors are seen frequently with virtual teams where a diagnosis isn’t communicated quickly … In the contract that I mentioned, the implementation of the Diagnosis Improvement Course will occur alongside … The Diagnosis Improvement Course will be part of the evaluation as well.

5590. Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training | PSNet
      psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
      February 28, 2024 - Diagnostic errors are seen frequently with virtual teams where a diagnosis isn’t communicated quickly … In the contract that I mentioned, the implementation of the Diagnosis Improvement Course will occur alongside … The Diagnosis Improvement Course will be part of the evaluation as well.

5591. Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic | PSNet
      psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
      January 12, 2022 - there were notable patient safety concerns associated with factors such as disease exposure, timely diagnosis … failure in patients with COVID-19 and sepsis requires them to be managed differently . 13 , 14 Timely diagnosis … demonstrated to decrease inpatient mortality for patients with sepsis, 16 but the need to confirm a COVID-19 diagnosis

5592. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46882/psn-pdf
      May 23, 2018 - How health care changes when algorithms start making diagnoses. … https://psnet.ahrq.gov/issue/how-health-care-changes-when-algorithms-start-making-diagnoses Use of artificial … intelligence and computer algorithms as tools to improve diagnosis have both risks and benefits. … This magazine article reports on how computer-assisted diagnosis can support accuracy and enable physicians … https://psnet.ahrq.gov/issue/how-health-care-changes-when-algorithms-start-making-diagnoses https://psnet.ahrq.gov

5593. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41454/psn-pdf
      October 23, 2012 - Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and … Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and … This study analyzed 56 missed or delayed cancer diagnoses and found that virtually all cases involved … https://psnet.ahrq.gov/issue/errors-cancer-diagnosis-current-understanding-and-future-directions https … ://psnet.ahrq.gov/issue/how-can-we-make-diagnosis-safer https://psnet.ahrq.gov/issue/missing-clinical-information-during-primary-care-visits

5594. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60269/psn-pdf
      April 29, 2020 - How could this happen, especially in regard to a life-threatening diagnosis? … In this era of sub-specialization of medicine and surgery, diagnoses tend to be assigned to the care … begin, a health system can create guidelines for emergency department consultations, built around diagnoses … physician (i.e., a senior resident or attending) see all or certain consults may help ensure that critical diagnoses … In addition, establishing ‘time to treatment’ quality metrics for critical diagnoses like https://psnet.ahrq.gov

5595. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853627/psn-pdf
      September 20, 2023 - strategies such as behavioral design, internet use, and prehospital practice play a role in the timing of diagnosis … understanding-and-addressing-pre-hospital-diagnostic-delays https://psnet.ahrq.gov/issue/missed-and-delayed-diagnoses-ambulatory-setting-study-closed-malpractice-claims … failure-follow-test-results-ambulatory-patients-systematic-review https://psnet.ahrq.gov/issue/crowdsourcing-diagnosis-patients-undiagnosed-illnesses-evaluation-crowdmed

5596. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866168/psn-pdf
      January 02, 2000 - Missed diagnoses of acute cardiac ischemia in the emergency department. … Missed diagnoses of acute cardiac ischemia in the emergency department. … https://psnet.ahrq.gov/issue/missed-diagnoses-acute-cardiac-ischemia-emergency-department Missed or … delayed diagnosis of cardiovascular disease can lead to adverse patient outcomes. … /issue/missed-diagnosis-new-onset-systolic-heart-failure-first-presentation-children-no-known-heart https

5597. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41814/psn-pdf
      March 04, 2015 - To assess the accuracy of both radiologic and pathologic diagnoses, this study directly compared diagnoses … Interestingly, the authors found cases where autopsies missed diagnoses that had been previously noted … on imaging tests, as well as cases where the premortem radiologic diagnosis proved to be incorrect … The authors advocate for routinely comparing pathologic and radiologic diagnoses as a mutual quality … An autopsy diagnosis that was missed on an initial radiograph is discussed in this AHRQ WebM&M commentary

5598. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38291/psn-pdf
      April 08, 2011 - Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States. … Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States. … Cognitive error on the part of physicians may contribute to misdiagnosis for these diagnoses. … A delayed diagnosis of meningitis is discussed in an AHRQ WebM&M commentary. … https://psnet.ahrq.gov/issue/importance-cognitive-errors-diagnosis-and-strategies-minimize-them https

5599. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40321/psn-pdf
      March 30, 2011 - inaccuracies-assignment-clinical-stage-localized-prostate-cancer For many types of cancer, the extent of disease at diagnosis … Diagnostic errors have also been documented in the pathologic diagnosis of cancer. … diagnostic-errors https://psnet.ahrq.gov/issue/clinical-impact-and-frequency-anatomic-pathology-errors-cancer-diagnoses … https://psnet.ahrq.gov/issue/clinical-impact-and-frequency-anatomic-pathology-errors-cancer-diagnoses

5600. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49774/psn-pdf
      November 01, 2016 - Identify obstetric hemorrhage when it is concealed or obscured by other obstetric diagnoses such as … Concealed hemorrhage in the context of additional pregnancy diagnoses that mask some of the key signs … Examples of confounding diagnoses include preeclampsia and other hypertensive disorders of pregnancy … contemplate a full set of differential diagnoses) and not focus on a specific diagnosis. … Postpartum hemorrhage—update on problems of definitions and diagnosis.