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21. Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia. | PSNet
    psnet.ahrq.gov/issue/care-and-oversight-deficiencies-related-multiple-homicides-louis-johnson-va-medical-center
    February 10, 2021 - July 27, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia. … July 5, 2006 VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility … Compliance with Screening Requirements is Poor. … Cancer at the Hampton VA Medical Center in Virginia.

22. Prescription Opioids: Medicare Needs to Expand Oversight Efforts to Reduce the Risk of Harm. | PSNet
    psnet.ahrq.gov/issue/prescription-opioids-medicare-needs-expand-oversight-efforts-reduce-risk-harm
    December 06, 2017 - July 5, 2006 VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility … Compliance with Screening Requirements is Poor. … July 27, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia. … Cancer at the Hampton VA Medical Center in Virginia.

23. Diagnostic Errors Case Studies | PSNet
    psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
    February 08, 2023 - was admitted for scheduled Cesarean delivery, before being tested according to a universal inpatient screening … The commentary discusses the challenges of screening for suicide risk and the importance of continuity … was admitted for scheduled Cesarean delivery, before being tested according to a universal inpatient screening

24. The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer. | PSNet
    psnet.ahrq.gov/issue/big-dog-effect-variability-assessing-causes-error-diagnoses-patients-lung-cancer
    December 19, 2007 - October 5, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia. … 29, 2020 Patient perspectives on the use of artificial intelligence for skin cancer screening … December 12, 2018 Ireland investigates cervical cancer screening scandal. … WebM&M Cases Hemolysis Holdup May 1, 2017 Breast cancer screening

25. Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events. | PSNet
    psnet.ahrq.gov/issue/veterans-health-care-veterans-health-administration-processes-responding-reported-adverse
    August 15, 2012 - July 5, 2006 VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility … Compliance with Screening Requirements is Poor. … July 27, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia. … Cancer at the Hampton VA Medical Center in Virginia.

26. Improving radiology report quality by rapidly notifying radiologist of report errors. | PSNet
    psnet.ahrq.gov/issue/improving-radiology-report-quality-rapidly-notifying-radiologist-report-errors
    May 29, 2019 - August 1, 2012 Comparison of traditional trigger tool to data warehouse based screening … 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia. … October 3, 2018 Double reading in breast cancer screening: cohort evaluation in the CO-OPS … June 15, 2016 Effect of using the same vs different order for second readings of screening

27. Periodic Issue | PSNet
    psnet.ahrq.gov/periodic-issue/periodic-issue-333
    March 31, 2022 - Study Estimation of breast cancer overdiagnosis in a U.S. breast screening cohort … Based on data from 35,986 women in a US-based breast cancer screening registry, this study estimates … Study Estimation of breast cancer overdiagnosis in a U.S. breast screening cohort … MD, MS | March 31, 2022 This Spotlight Case describes an older man incidentally diagnosed with prostate … cancer, with metastases to the bone.

28. Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida. | PSNet
    psnet.ahrq.gov/issue/patient-suicide-locked-mental-health-unit-west-palm-beach-va-medical-center-florida
    August 02, 2023 - March 16, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia. … July 5, 2006 VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility … Compliance with Screening Requirements is Poor. … Cancer at the Hampton VA Medical Center in Virginia.

29. Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. | PSNet
    psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city-healthcare-system
    August 02, 2023 - March 16, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia. … July 5, 2006 VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility … Compliance with Screening Requirements is Poor. … Cancer at the Hampton VA Medical Center in Virginia.

30. Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin. | PSNet
    psnet.ahrq.gov/issue/unexpected-death-patient-during-treatment-multiple-medications-tomah-va-medical-center-tomah
    October 12, 2022 - July 27, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia. … July 5, 2006 VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility … Compliance with Screening Requirements is Poor. … Cancer at the Hampton VA Medical Center in Virginia.

31. VA Patient Safety Program: A Cultural Perspective at Four Medical Facilities. | PSNet
    psnet.ahrq.gov/issue/va-patient-safety-program-cultural-perspective-four-medical-facilities
    October 26, 2022 - July 5, 2006 VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility … Compliance with Screening Requirements is Poor. … Cancer at the Hampton VA Medical Center in Virginia. … , 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia.

32. What causes delays in diagnosing blood cancers? A rapid review of the evidence. | PSNet
    psnet.ahrq.gov/issue/what-causes-delays-diagnosing-blood-cancers-rapid-review-evidence
    August 14, 2019 - September 21, 2022 Quantifying and monitoring overdiagnosis in cancer screening: a systematic … April 27, 2011 Overdiagnosis in low-dose computed tomography screening for lung cancer … August 3, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia.

33. Actions Needed to Address Employee Misconduct Process and Ensure Accountability. | PSNet
    psnet.ahrq.gov/issue/actions-needed-address-employee-misconduct-process-and-ensure-accountability
    May 16, 2018 - July 5, 2006 VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility … Compliance with Screening Requirements is Poor. … July 5, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia. … Cancer at the Hampton VA Medical Center in Virginia.

34. Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee. | PSNet
    psnet.ahrq.gov/issue/healthcare-inspection-emergency-department-patient-deaths-memphis-vamc-memphis-tennessee
    February 10, 2021 - July 27, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia. … July 5, 2006 VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility … Compliance with Screening Requirements is Poor. … Cancer at the Hampton VA Medical Center in Virginia.

35. VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events. | PSNet
    psnet.ahrq.gov/issue/va-health-care-actions-needed-assess-decrease-root-cause-analyses-adverse-events
    November 22, 2017 - July 5, 2006 VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility … Compliance with Screening Requirements is Poor. … July 5, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia. … Cancer at the Hampton VA Medical Center in Virginia.

36. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. | PSNet
    psnet.ahrq.gov/issue/variability-diagnostic-error-rates-10-mri-centers-performing-lumbar-spine-mri-examinations
    July 17, 2013 - Artificial intelligence-supported screen reading versus standard double reading in the Mammography Screening … August 23, 2023 Breast cancer missed at screening; hindsight or mistakes? … August 10, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia. … July 8, 2022 Multilevel factors associated with time to biopsy after abnormal screening

37. Anemia and Delayed Colon Cancer Diagnosis | PSNet
    psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
    October 01, 2008 - List common errors in management of iron deficiency anemia and colon cancer screening. … A colonoscopy for colorectal cancer screening was normal 2 years prior to this presentation. … Clinical practice guidelines: quality of colonoscopy in colorectal cancer screening. … Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. … Colorectal cancer screening: recommendations for physicians and patients from the U.S.

38. Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System. | PSNet
    psnet.ahrq.gov/issue/interim-report-review-vhas-patient-wait-times-scheduling-practices-and-alleged-patient-deaths
    September 10, 2014 - July 26, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia. … July 5, 2006 VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility … Compliance with Screening Requirements is Poor. … Cancer at the Hampton VA Medical Center in Virginia.

39. Medication safety in neonatal care: a review of medication errors among neonates. | PSNet
    psnet.ahrq.gov/issue/medication-safety-neonatal-care-review-medication-errors-among-neonates
    July 27, 2022 - May 22, 2019 Inaccuracies in assignment of clinical stage for localized prostate cancer … June 28, 2017 Clinicians' expectations of the benefits and harms of treatments, screening

40. Drugmakers are abandoning cheap generics, and now US cancer patients can’t get meds. | PSNet
    psnet.ahrq.gov/issue/drugmakers-are-abandoning-cheap-generics-and-now-us-cancer-patients-cant-get-meds
    September 20, 2023 - November 10, 2021 Follow-up of abnormal screening mammograms among low-income ethnically … July 7, 2021 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate … Cancer at the Hampton VA Medical Center in Virginia.