-
psnet.ahrq.gov/node/837743/psn-pdf
July 27, 2022 - dropping-ball-despite-integrated-emr
https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
-
psnet.ahrq.gov/node/853068/psn-pdf
August 30, 2023 - ://psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
-
psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
July 19, 2023 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without … Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without … Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without … Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without
-
psnet.ahrq.gov/node/860714/psn-pdf
January 17, 2024 - issue/burden-serious-harms-diagnostic-error-usa
https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
-
psnet.ahrq.gov/node/41800/psn-pdf
November 07, 2012 - effects-electrode-misplacement-clinicians-interpretation-standard-12-lead-
electrocardiogram
Misplacement of the electrical leads
-
psnet.ahrq.gov/node/863216/psn-pdf
February 28, 2024 - psnet.ahrq.gov/primer/duty-hours-and-patient-safety
https://psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
-
psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads … Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads … Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads … Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads … March 1, 2023
WebM&M Cases
Lack of Sepsis Recognition Leads
-
psnet.ahrq.gov/node/72525/psn-pdf
December 02, 2020 - breast-cancer-treatment-delays-socioeconomic-and-health-care-access-latent-classes-black-and
https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
-
psnet.ahrq.gov/node/836724/psn-pdf
March 09, 2022 - when-no-news-bad-news-improving-diagnostic-testing-communication-through-patient-engagement
https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
-
psnet.ahrq.gov/node/842417/psn-pdf
January 11, 2023 - pharmacist-led-information-technology-intervention-medication-errors-pincer-multicentre
https://psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death
-
psnet.ahrq.gov/node/60179/psn-pdf
April 01, 2020 - control up to individuals and groups of healthcare practitioners; the author describes how this culture leads
-
psnet.ahrq.gov/node/867087/psn-pdf
January 01, 2025 - factors-influencing-second-victim-experiences-and-support-needs-obgyn-and-pediatric
https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
-
psnet.ahrq.gov/node/866526/psn-pdf
August 14, 2024 - primer/long-term-care-and-patient-safety
https://psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
-
psnet.ahrq.gov/node/854831/psn-pdf
January 01, 2024 - ://psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
-
psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. … Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016. … https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant … handoffs and transitions, and the benefits and risks
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
-
psnet.ahrq.gov/node/49595/psn-pdf
December 01, 2009 - "Superficial" Report Leads to "Deep" Problem
December 1, 2009
Dhaliwal G. … "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009. … https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
The Case
A 35-year-old woman presented … The
https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
patient returned promptly
-
psnet.ahrq.gov/node/865710/psn-pdf
May 01, 2024 - managers-perceptions-factors-affecting-resident-and-patient-safety-work-residential-settings
https://psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
-
psnet.ahrq.gov/node/72572/psn-pdf
January 01, 2021 - home-care-lessons-new-york-city-home-based-primary-care-practices-managing-covid-19
https://psnet.ahrq.gov/issue/fear-covid-19-leads-other-patients-decline-critical-treatment
-
psnet.ahrq.gov/node/72471/psn-pdf
November 18, 2020 - deferral-care-serious-non-covid-19-conditions-hidden-harm-covid-19
https://psnet.ahrq.gov/issue/fear-covid-19-leads-other-patients-decline-critical-treatment
-
psnet.ahrq.gov/node/837807/psn-pdf
August 10, 2022 - root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis