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psnet.ahrq.gov/issue/framing-clinical-information-affects-physicians-diagnostic-accuracy
November 02, 2011 - WebM&M Cases
Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary
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psnet.ahrq.gov/issue/first-do-no-harm-balancing-competing-priorities-surgical-practice
December 12, 2012 - Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary
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psnet.ahrq.gov/issue/relationship-between-hospital-adverse-events-and-hospital-performance-30-day-all-cause
June 22, 2022 - medication reconciliation at discharge on 30-day readmission rates of patients with chronic obstructive pulmonary
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psnet.ahrq.gov/issue/harnessing-situ-simulation-identify-human-errors-and-latent-safety-threats-adult-tracheostomy
September 23, 2020 - More About The Topic
Hospitals
Allied Health Services
Hospital Medicine
Nurse Care
Pulmonary
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psnet.ahrq.gov/issue/clinical-diagnoses-and-autopsy-findings-discrepancies-critically-ill-patients
March 09, 2022 - Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary
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psnet.ahrq.gov/issue/neurobehavioral-performance-residents-after-heavy-night-call-vs-after-alcohol-ingestion
June 22, 2022 - Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary
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psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - The evaluation focused instead on possible pulmonary embolism in the setting of a minimally positive … Gastroesophageal reflux disease, pulmonary embolism, asthma, and pleurisy are often on the differential … for evaluation of frequent nocturnal chest pain, the primary workup done in the ED was to rule out pulmonary
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psnet.ahrq.gov/node/49480/psn-pdf
May 01, 2005 - Later the patient died of a myocardial infarction and pulmonary edema. … Several radiologists reviewed the chest x-ray (after the outcome) and reported it “consistent” with
pulmonary … For example, MI,
acute coronary syndrome (ACS), pulmonary embolus (PE), and AD are all in the differential
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psnet.ahrq.gov/node/49550/psn-pdf
December 01, 2007 - family's request, no autopsy was performed; however, providers felt that the
patient suffered a massive pulmonary … thromboembolism prophylaxis at the time of hip fracture surgery
(as this patient received) developed a fatal pulmonary … embolism.(1) Even if the patient in this case did not
die of pulmonary embolism, she would be considered
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psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
May 01, 2012 - recurrent blood clots and heparin-induced thrombocytopenia, was admitted to the next room with a new pulmonary … her IV pole was labeled as argatroban—but the name on the label matched that of the patient with the pulmonary
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psnet.ahrq.gov/node/49588/psn-pdf
August 01, 2009 - Part 1
A 68-year-old man was admitted to the intensive care unit (ICU) with chronic obstructive pulmonary … transferred from the overflowing
emergency department with hemodynamic instability from a massive pulmonary … The nurse then hurriedly returned to the bedside of the acutely ill patient
with the pulmonary embolism
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
August 01, 2009 - 30 minutes, a second patient was transferred from the ED with hemodynamic instability from a massive pulmonary … The nurse then rushed to the bedside of the acutely ill patient with the pulmonary embolism.
*
Case
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psnet.ahrq.gov/node/49656/psn-pdf
June 01, 2012 - /web-mm/comanagement-whos-charge
The Case
A 77-year-old man with a history of chronic obstructive pulmonary … A
computed tomography (CT) angiogram was done, which was negative for pulmonary embolism but showed
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psnet.ahrq.gov/node/61080/psn-pdf
October 28, 2020 - This process leads to arrythmias including ST and T wave changes,
neurogenic pulmonary edema, hypertension … Neurogenic pulmonary edema. Crit Care. 2012;16:212.
10.
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psnet.ahrq.gov/node/49548/psn-pdf
October 01, 2007 - The pulmonary, cardiovascular, skin, and neurologic
examinations were all unremarkable. … Or the precipitant may be severe
thermal injury, diabetic ketoacidosis, pulmonary thromboembolism, or
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psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
January 01, 2018 - paste.( 1 ) In that case, the patient with an alleged history of "PE" (interpreted by the clinicians as pulmonary … embolism) received an unnecessary CT scan to rule out a suspected "recurrence" of pulmonary embolus. … been used in the electronic note to indicate that the patient had had a physical examination, not a pulmonary … In a vivid example of copy and paste, once the diagnosis of pulmonary embolism was mistakenly given to … in that you know you're not going to find anything in listening to the lungs in someone who has no pulmonary
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - On the second hospital day, the patient had increased pulmonary secretions. … wide range of diagnostic, therapeutic, and research purposes, and it is regarded as a cornerstone of pulmonary
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psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
November 13, 2024 - Case #2:
A 53-year-old woman with a history of chronic obstructive pulmonary disease (COPD) on home … Score
Absent
0
Mild (pedal edema)
5
Moderate (bibasilar rales)
10
Severe (pulmonary … 49
20
<40
30
Other ECG changes*
10
Pericardial/pleural effusions
10
Pulmonary
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psnet.ahrq.gov/node/865570/psn-pdf
April 10, 2024 - 2) a high body mass index (greater than or equal to
45) who are undergoing general anesthesia, (3) pulmonary … The NAPSI team does not collect data about patient history of pulmonary hypertension or any known or
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psnet.ahrq.gov/issue/detectability-medication-errors-stoppstart-based-medication-review-older-people-prior
August 18, 2021 - medication reconciliation at discharge on 30-day readmission rates of patients with chronic obstructive pulmonary