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psnet.ahrq.gov/web-mm/monitoring-fetal-health
September 08, 2010 - infant subsequently had multiple seizures typical of hypoxic-ischemic encephalopathy (brain injury from inadequate
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - Unfortunately, the patient was given an inadequate diagnosis and was discharged while still in pain.
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - Possible Artifact
June 30, 2021
WebM&M Cases
Inadequate
-
psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - unsuccessful handoffs include conflicting expectations between sender and receiver, cultural
differences, inadequate
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psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
October 31, 2023 - Related Resources
WebM&M Cases
Missed Connection: A Case of Inadequate
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psnet.ahrq.gov/web-mm/ebola-are-we-ready
July 01, 2012 - Checklists and procedures create the foundation or infrastructure for safe processes, but are completely inadequate
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psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
August 14, 2024 - Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
May 29, 2024
-
psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
August 01, 2016 - Second, the inadequate management of postsurgical infections.
-
psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - back systems are
ineffective
Lack of knowledge
about radiographic
appearance of
surgical items
Inadequate
-
psnet.ahrq.gov/perspective/conversation-maureen-bisognano
February 26, 2025 - that doesn't have enough staffing on the night shift, or a unit that has all young new people with inadequate
-
psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - mitigating common safety issues such as diagnostic delays and errors; medication-related safety events; inadequate … Patient-clinician communication Coordination across settings of care Continuity of care Access to care Inadequate
-
psnet.ahrq.gov/node/84413/psn-pdf
February 23, 2022 - System-related errors, which include technological or organizational barriers
Cognitive errors, which include inadequate
-
psnet.ahrq.gov/node/848107/psn-pdf
April 26, 2023 - Improving Diagnostic Safety and Quality
April 26, 2023
Al-Khafaji J, Lee M, Mossburg S. Improving Diagnostic Safety and Quality . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
Introduction
During an annual editorial review of featured articles in the Agency for …
-
psnet.ahrq.gov/node/866826/psn-pdf
September 25, 2024 - Hypoxic Gas Supply from Cross-Connected Pipelines
September 25, 2024
Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
The Case
An 8-year-old boy with no significant past medical…
-
psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
February 22, 2017 - SPOTLIGHT CASE
Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees
Citation Text:
Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
-
psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
January 31, 2024 - Annual Perspective
Improving Diagnostic Safety and Quality
Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD
| April 26, 2023
View more articles from the same authors.
Citation Text:
Al-Khafaji J, Lee M, Mossburg S. Improving Di…
-
psnet.ahrq.gov/perspective/safety-dentistry
August 01, 2016 - Second, the inadequate management of postsurgical infections.
-
psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - transplant surgery
Prolonged surgery (> 2
hours)
Patient-controlled analgesia
(with basal rate)
Inadequate
-
psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
January 01, 2024 - management of AIS, an
emphasis on collateral information is important when the medical history
is inadequate
-
psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-postdischarge-needs
March 27, 2024 - This lack of preparation and inadequate followup care make patients vulnerable to medication errors,