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psnet.ahrq.gov/web-mm/suicidal-man-gun
May 01, 2005 - within the entire spectrum of psychiatric illness, this case would be difficult to manage even for an experienced
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - Although the patient did not experience any direct harm from the lidocaine, he could have experienced
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psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
February 23, 2011 - Take-Home Point Patient misidentification is a medical error experienced across all medical departments
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psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - June 1, 2011
A 62-year-old woman with skin cancer who experienced wrong-site surgery.
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psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
October 01, 2018 - He subsequently experienced acute onset of shortness of breath associated with a "whistling sound" from
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psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
January 05, 2017 - One day after re-initiation of his warfarin, he experienced a recurrence of his subdural hematoma.
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psnet.ahrq.gov/node/49630/psn-pdf
July 01, 2011 - to recommend that patients who had changes in their warfarin dose, had new medications
started, or experienced
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psnet.ahrq.gov/web-mm/wheres-feeding-tube
September 01, 2003 - The Case A 13-year-old boy was involved in a motor vehicle collision and experienced a traumatic
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - discontinuities in care or communication.( 3 ) In one U.S. teaching hospital, 19% of discharged medical patients experienced
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psnet.ahrq.gov/web-mm/dressed-failure
September 01, 2011 - An integrated EHR at Northern California Kaiser Permanente: pitfalls, challenges, and benefits experienced
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psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - were not noted so we don’t know whether she also may have suffered a drop in her blood pressure and experienced
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psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
November 27, 2023 - excited about that and believe that the Essentials will help to address many of the issues we have experienced … It may not be what they’ve experienced or been taught in their program.
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psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
November 27, 2023 - excited about that and believe that the Essentials will help to address many of the issues we have experienced … It may not be what they’ve experienced or been taught in their program.
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psnet.ahrq.gov/node/33613/psn-pdf
May 01, 2005 - Organizational Change in the Face of Highly Public
Errors—II. The Duke Experience
May 1, 2005
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSNet
[internet]. 2005.
https://psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
Pe…
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - We are told that the patient in this case experienced a "worsening" of his pain after his surgery, but
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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - Conversions to methadone or buprenorphine are best implemented by an experienced clinician. 25 Third
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psnet.ahrq.gov/node/33587/psn-pdf
June 15, 2024 - Missed Nursing Care
June 15, 2024
Missed Nursing Care. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/missed-nursing-care
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed…
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
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psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - were not noted so we don’t know whether she also may have suffered a drop in her blood
pressure and experienced
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psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
July 01, 2017 - worker's comp claims, social security disability insurance, vaccine injury claims—a process by which experienced … standard that compensates patients whenever an outcome could have been prevented in the hands of an experienced