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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
September 15, 2025 - Two months after his admission for cholecystitis, he was readmitted for severe vomiting and hypotension … When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred … Confusion regarding biopsy scheduling led to delays and, 7 months after initial presentation, the patient
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psnet.ahrq.gov/node/35330/psn-pdf
April 04, 2021 - "Talk About Your Medicines" Month.
April 4, 2021
BeMedWise Program at NeedyMeds, Gloucester, MA.
https://psnet.ahrq.gov/issue/talk-about-your-medicines-month
This Web site provides information and tools that support an educational campaign to encourage high-
quality communication about medication use. The annual o…
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psnet.ahrq.gov/node/41187/psn-pdf
October 16, 2012 - At 6 months following the intervention, patients in the
PINCER group experienced substantially reduced
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psnet.ahrq.gov/node/41223/psn-pdf
March 21, 2012 - experienced a decrease in inpatient admissions and new patient
visits, but the effect dissipated 6 months
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psnet.ahrq.gov/node/43253/psn-pdf
May 01, 2015 - average wait times of only 24 days, the investigation found
that veterans typically waited nearly 4 months
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psnet.ahrq.gov/node/45310/psn-pdf
January 03, 2017 - These cases included many
patients who had no documented health care visits in the 6 months after the
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psnet.ahrq.gov/node/46747/psn-pdf
June 06, 2018 - common in the ambulatory care setting, but they can be difficult to detect because
patients may spend months
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psnet.ahrq.gov/node/39952/psn-pdf
October 27, 2010 - Specimen labeling errors in surgical pathology: an 18-
month experience.
October 27, 2010
Layfield LJ, Anderson GM. Specimen labeling errors in surgical pathology: an 18-month experience. Am J
Clin Pathol. 2010;134(3):466-70. doi:10.1309/AJCPHLQHJ0S3DFJK.
https://psnet.ahrq.gov/issue/specimen-labeling-errors-surgi…
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psnet.ahrq.gov/node/49602/psn-pdf
April 01, 2010 - Patients at the highest TE risk
(e.g., mechanical mitral valve or VTE within the prior 3 months) typically … receive bridging anticoagulation,
while patients at the lowest risk (e.g., single VTE event >12 months … bileaflet
mechanical aortic valve
replacement with no other risk
factors, single prior VTE >12
months … HIGH (Atrial fibrillation with
CHADS score 5-6, mechanical
mitral valve, VTE within 3
months)
Low
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psnet.ahrq.gov/node/49840/psn-pdf
September 01, 2018 - During medication reconciliation, it was discovered that 2 months prior to this illness, the patient … corticosteroids were never tapered, and she had continued to take high-dose steroids for more than 2
months … She
remained at the nursing facility for more than 2 months before returning home. … psnet.ahrq.gov//#references
especially in higher-risk patients and when the duration of treatment is 3 months
-
psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
August 21, 2005 - caged-ball, single-disk), or a history of stroke or transient ischemic attack (TIA) within the preceding 6 months … the INR falls from 2.0 down to 1.0. 5 However, patients with a mechanical aortic valve may survive months … 1972 and 1982, and who received anticoagulation treatment for only approximately 1 year (mean = 13 months … , range 4-35 months) thereafter, for an average of 7.25 years.
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psnet.ahrq.gov/node/73202/psn-pdf
April 28, 2021 - We have come to learn a great deal about COVID-19 in the ensuing
months, but the first months of the … type of false positive RT-PCR result
occurs when nonviable SARS-CoV-2 particles are detected weeks to months … CDC recommends avoiding follow-up
testing for patients with a positive SARS-CoV-2 result for three months … it will be important to learn from the errors
and limitations of our practices during its initial months
-
psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - We have come to learn a great deal about COVID-19 in the ensuing months, but the first months of the … type of false positive RT-PCR result occurs when nonviable SARS-CoV-2 particles are detected weeks to months … CDC recommends avoiding follow-up testing for patients with a positive SARS-CoV-2 result for three months … , it will be important to learn from the errors and limitations of our practices during its initial months
-
psnet.ahrq.gov/node/865610/psn-pdf
April 24, 2024 - an ED visit or hospitalization due to suicidal
ideation/behavior or 2) death by suicide in the six months … included an ED visit or hospitalization due to suicidal ideation/behavior or death by suicide in the six
months
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psnet.ahrq.gov/issue/latest-heparin-fatality-speaks-loudly-what-have-you-done-stop-bleeding
May 03, 2023 - June 10, 2018
Any new process poses a risk for errors: learning from 4 months of Coronavirus
-
psnet.ahrq.gov/issue/bbc-news-wrong-guy-revealed
August 05, 2020 - September 1, 2010
Hospital bosses ignored months of doctors' warnings about Lucy Letby
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psnet.ahrq.gov/issue/covid-19-leads-increased-need-dialysis-machines
April 29, 2020 - Related Resources
Top Penn State Health surgeon warned leaders about transplant problems months
-
psnet.ahrq.gov/issue/warning-missed-patient-safety-alerts-nhs
August 30, 2023 - Citation
Related Resources From the Same Author(s)
Hospital bosses ignored months
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psnet.ahrq.gov/improvement-tools
February 26, 2025 - The first 13 months of...
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psnet.ahrq.gov/node/73998/psn-pdf
October 27, 2021 - anesthesiology fellowships accredited by the Accreditation Council for Graduate
Medical Education complete 12 months … program requires a
pediatric anesthesiologist to perform or supervise care for any child less than 6-months-old … uniquely qualified to care for patients
such as the infant in the highlighted case, who was less than 6-months-old