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psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
January 31, 2011 - While being evaluated by the emergency physician, he suddenly went into cardiac arrest.
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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - may be
needed to mitigate the possible effects of implicit bias on how post-
procedural symptoms are evaluated
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psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
November 08, 2013 - The emergency physician spoke with the intensivist, who reassured her that the nephrologist had evaluated
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psnet.ahrq.gov/node/49804/psn-pdf
September 01, 2017 - Case & Commentary—Part 2
The overnight hospitalist evaluated the patient but decided not to administer
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psnet.ahrq.gov/node/49795/psn-pdf
June 01, 2017 - The patient was
evaluated by vascular surgery who recommended conservative management with intravenous
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psnet.ahrq.gov/node/49621/psn-pdf
March 01, 2011 - His aunt
assumed this was due to the viral infection, and the child was not evaluated by the nurse during
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psnet.ahrq.gov/node/33683/psn-pdf
April 01, 2009 - Second, changes must be evaluated for effectiveness, ideally both before (ex ante evaluation) and after
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psnet.ahrq.gov/node/49752/psn-pdf
January 01, 2016 - Inadvertent Use of More Potent Acid Leads to Burn
January 1, 2016
Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
The Case
A 31-year-old woman came to the clinic for a routine well-woman evaluation. She…
-
psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root
Cause Analysis
July 1, 2008
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
Perspective
Throughout most of his life, …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.72_slideshow.ppt
September 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case September 2004
Poor Prognosis?
Source and Credits
This presentation is based on the September 2004
AHRQ WebM&M Spotlight Case in Surgery
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Elizabeth B. Lamont, M…
-
psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - event, which BWH researchers believe was in alignment with current national standards of care, was evaluated
-
psnet.ahrq.gov/issue/breast-cancer-missed-screening-hindsight-or-mistakes
November 15, 2023 - January 29, 2020
Why Current Breast Pathology Practices Must Be Evaluated.
-
psnet.ahrq.gov/issue/discrepancies-between-clinical-and-autopsy-diagnosis-and-value-post-mortem-histology-meta
September 22, 2021 - March 23, 2012
Why Current Breast Pathology Practices Must Be Evaluated.
-
psnet.ahrq.gov/issue/missed-lesions-abdominal-oncologic-ct-lessons-learned-quality-assurance
April 21, 2011 - October 4, 2011
Why Current Breast Pathology Practices Must Be Evaluated.
-
psnet.ahrq.gov/issue/evaluation-12-strategies-obtaining-second-opinions-improve-interpretation-breast
November 03, 2015 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
-
psnet.ahrq.gov/issue/characteristics-and-predictors-missed-opportunities-lung-cancer-diagnosis-electronic-health
January 19, 2012 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
-
psnet.ahrq.gov/issue/diagnostic-errors-musculoskeletal-oncology-and-possible-mitigation-strategies
May 01, 2013 - December 27, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
-
psnet.ahrq.gov/issue/big-dog-effect-variability-assessing-causes-error-diagnoses-patients-lung-cancer
March 28, 2012 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
-
psnet.ahrq.gov/issue/delayed-or-missed-diagnosis-cervical-spine-injuries
May 05, 2010 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
-
psnet.ahrq.gov/issue/patient-safety-leadership-academy-university-pennsylvania-first-cohorts-learning-experience
October 04, 2011 - June 18, 2013
Why Current Breast Pathology Practices Must Be Evaluated.