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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 - gallbladder, should have prompted a surgical consultation for acute cholecystitis, which might have led
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psnet.ahrq.gov/web-mm/monitoring-fetal-health
September 08, 2010 - Although well intended, there are two fundamental differences inherent in centralized monitoring that have led
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - Later, problems with data gathering and information processing led to a brief delay in recognizing emerging
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - Getting Started The RCA team is usually led by a member of the institution’s patient safety or quality
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - failure to perform a complete hand examination and appropriately manage and refer a high-risk laceration led
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psnet.ahrq.gov/node/867805/psn-pdf
February 26, 2025 - The catheter-related
bloodstream work, which was led by Dr.
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psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
February 26, 2025 - Ten years from now, people will probably still say that the projects that led to checklists being the
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting Started
The RCA team is usually led by a member of the institution’s patient safety or quality
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psnet.ahrq.gov/node/33728/psn-pdf
May 01, 2012 - The initial focus of
patient safety on errors attracted a lot of interest, and led to the idea that
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - system-oriented processes that hospital
quality improvement professionals had previously implemented, led
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psnet.ahrq.gov/node/49597/psn-pdf
February 01, 2010 - sexual history in a confidential setting may have revealed this patient's prior
sexual assault and led
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psnet.ahrq.gov/perspective/conversation-shantanu-nundy-md
February 26, 2025 - And that led to the name "The Human Diagnosis Project."
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psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - This led to a framing error and premature
closure around isolated cardiac pathology.
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - The nurse manager for the unit led a root cause analysis to determine what had happened.
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - This led to a prolonged intensive care unit (ICU) stay for respiratory failure from an ischemic cardiac
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psnet.ahrq.gov/node/60267/psn-pdf
March 01, 2021 - Vermont Blueprint for Health leaders to
include the program in its application to CMS, which ultimately led
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psnet.ahrq.gov/node/836879/psn-pdf
April 27, 2022 - Absent that media spotlight, the same facts would have led to the same inaction that had continued for
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psnet.ahrq.gov/web-mm/july-syndrome
July 01, 2011 - July Syndrome
Citation Text:
Young JQ. July Syndrome. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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D…
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psnet.ahrq.gov/web-mm/obstructed-view
August 07, 2019 - An Obstructed View
Citation Text:
Carter J. An Obstructed View. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - intubation during general anesthesia. 28 It is possible that her obesity, and perhaps other social factors, led