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psnet.ahrq.gov/innovations
February 26, 2025 - Credentialing, Licensure, and Discipline
(1)
Logistical Approaches
(5)
Laboratory
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psnet.ahrq.gov/web-mm/complaints-safety-surveillance
May 05, 2021 - Her laboratory studies showed elevated amylase and lipase, and a CT scan confirmed the diagnosis of acute
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psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
September 01, 2017 - conscientious clinicians make simple mistakes or completely miss or fail to comprehend key abnormal laboratory
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psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
January 03, 2017 - The ED obtained routine laboratory tests (including urinalysis and complete blood count [CBC]) that indicated
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psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - would be a mistake to assume that lack of objective signs or the presence of atypical historical or laboratory
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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - The plan was to obtain laboratory studies, administer methylprednisolone, and then monitor for resolution
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psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
February 23, 2022 - The patient’s laboratory results were notable for acute kidney injury and metabolic acidosis, with an
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - This may include addressing what happens in physicians' offices as well as in radiology and laboratory
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
January 01, 2024 - (IV) bolus of one liter of normal saline and ibuprofen for her headache.
5
5
Case Details (2)
Laboratory
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
January 01, 2024 - clinical information about a patient, including historical details, serial physical exam findings, laboratory
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psnet.ahrq.gov/web-mm/techno-trip
May 01, 2005 - MD Associate Professor, Department of Anesthesia and Critical Care Director, Cognitive Technologies Laboratory
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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - Symptoms, signs, and laboratory abnormalities that should raise suspicion of retroperitoneal bleed include
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psnet.ahrq.gov/web-mm/worst-headache
July 01, 2016 - xanthochromia must be measured by spectrophotometry; however this technique is not used in 99% of hospital laboratories
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psnet.ahrq.gov/node/49779/psn-pdf
January 01, 2017 - Multiple intravenous infusions phase 2b: laboratory study.
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psnet.ahrq.gov/node/33696/psn-pdf
June 01, 2010 - An emergency department—which some people have described as a natural
laboratory for error—is a chaotic
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psnet.ahrq.gov/node/49699/psn-pdf
February 01, 2014 - age, weight, allergies,
diagnoses, and pregnancy status)
• Patient-monitoring information (e.g., laboratory
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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - Her laboratory
data was notable for an elevated white blood cell (WBC) count of 23,000/mm3, acute kidney
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - and resident
6
Case Details
• The ED care team:
– Obtained vascular access
– Sent a battery of laboratory
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psnet.ahrq.gov/node/33842/psn-pdf
January 01, 2018 - have included: (i) exploration of the processes involved in identifying
and communicating abnormal laboratory
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - Laboratory testing was ordered for follow-up and monitoring.