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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - Related Resources
Patient Safety Innovations
Critical Radiology
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psnet.ahrq.gov/node/49771/psn-pdf
July 01, 2016 - records and decision support systems,
and enables faster data and order transmission to pharmacy and radiology
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psnet.ahrq.gov/node/49615/psn-pdf
December 01, 2010 - redistribution surfaces in the ED or on the inpatient unit remain on the surface when transported to
Radiology
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - controlled surgically, the patient may need evaluation for an endovascular solution with interventional radiology
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psnet.ahrq.gov/node/49774/psn-pdf
November 01, 2016 - devices are
unsuccessful and bleeding continues, uterine artery embolization using interventional radiology
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psnet.ahrq.gov/node/33764/psn-pdf
April 01, 2014 - If a patient receives a test result or a radiology report with something concerning and they see that
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psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
December 02, 2020 - interventional radiologist discussed the case and decided to take the patient to the interventional radiology
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psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
April 03, 2024 - July 26, 2023
Assigning responsibility to close the loop on radiology test results.
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psnet.ahrq.gov/node/846169/psn-pdf
March 15, 2023 - Availability is also necessary in other places like interventional radiology or
endoscopy suites, post
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psnet.ahrq.gov/node/850450/psn-pdf
June 14, 2023 - minutes later the patient was found by an Environmental Services staff member
in a bathroom in the radiology
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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - could have been avoided if
any of the team members had communicated a verbal order directly to a
radiology
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psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
November 16, 2022 - December 27, 2014
Medical errors arising from outsourcing laboratory and radiology services
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psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - The senior resident reviewed all of the radiology records and read the original ultrasound report, which
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psnet.ahrq.gov/node/867357/psn-pdf
December 18, 2024 - When patients are transported to radiology, the intensive care unit or the operating room, the ETT may
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psnet.ahrq.gov/node/74251/psn-pdf
January 26, 2022 - Delayed Diagnosis and Treatment of an Occult
Hemothorax Following Complicated Central Line Insertion
Leads to Cardiac Arrest
January 26, 2022
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated
Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022.
https…
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/node/854848/psn-pdf
October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures
October 31, 2023
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
The Case
A 32-year-old man presented to the hospital with…
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psnet.ahrq.gov/node/49798/psn-pdf
July 01, 2017 - Pseudo-obstruction But a Real Perforation
July 1, 2017
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
Case Objectives
Recognize acute colonic pseudo-obstruction and implement a medical management plan.
Ide…
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psnet.ahrq.gov/node/49480/psn-pdf
May 01, 2005 - Diagnosing Diagnostic Mistakes
May 1, 2005
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
Learning Objectives
Understand the biases that may contribute to overcalling medical errors
Describe the impact of conside…
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psnet.ahrq.gov/node/33702/psn-pdf
November 01, 2010 - In Conversation with...Patrick S. Romano, MD, MPH
November 1, 2010
In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
Editor's note: Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the Universit…