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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - spinal
epidural abscess
• Evaluate for spinal epidural abscess with laboratory testing and
imaging
• Recognize … differential diagnosis at each subsequent visit
despite worsening signs and symptoms
– Failure to recognize … exemplify
anchoring bias when clinicians become “anchored” to an incorrect
diagnosis
– Failure to recognize … incorrect diagnosis of meningitis.
– Each of this patient’s visits represented a missed opportunity to recognize
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psnet.ahrq.gov/node/837660/psn-pdf
July 08, 2022 - Recognize persistent neuromuscular blockade prior to extubation
In retrospect, the persistent weakness … relayed to either the pulmonologist or the anesthesiologist because the junior staff member did not
recognize … If the patient does not recognize the significance of the event, it is unlikely
that the problem will
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psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
September 30, 2020 - Actively recognize MEWS - Maternal Early Warning Signs for obstetric hemorrhage. … Recognize the importance of standardized protocols and built-in alerts to help to address staggering … As health care providers, we must recognize our potential for implicit bias and acknowledge that patients
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psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
April 12, 2023 - Case Objectives
Recognize that transfer of patients between acute care hospitals is common. … Recognize that further research is needed to establish best practice guidelines with regard to the interhospital … The ambulance transport team was not trained to provide critical care and did not recognize that the
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psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
January 01, 2020 - Physician did not recognize the ECG abnormalities as consistent
with intracranial hemorrhage
3. … studies used to evaluate chest pain
with the possibility of myocardial ischemia
• ED physicians need to recognize
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psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
June 16, 2021 - The nurse did not recognize that it was unusual to use 32 vials of phenytoin to obtain the required dose … Clinicians can train themselves to recognize warnings associated with medication errors.
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psnet.ahrq.gov/node/49667/psn-pdf
October 01, 2012 - The nurse did not recognize that it was unusual to use 32 vials of phenytoin to obtain the required dose … Clinicians can train themselves to recognize warnings associated with medication errors.
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psnet.ahrq.gov/node/37746/psn-pdf
May 14, 2008 - Reducing preventable medication safety events by
recognizing renal risk.
May 14, 2008
Fields W, Tedeschi C, Foltz J, et al. Reducing preventable medication safety events by recognizing renal
risk. Clin Nurse Spec. 2008;22(2):73-8; quiz 79-80. doi:10.1097/01.NUR.0000311795.69476.2f.
https://psnet.ahrq.gov/issue/red…
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psnet.ahrq.gov/node/42981/psn-pdf
March 19, 2014 - Recognizing and managing errors of cognitive
underspecification.
March 19, 2014
Duthie EA. Recognizing and managing errors of cognitive underspecification. J Patient Saf. 2014;10(1):1-5.
doi:10.1097/PTS.0b013e3182a5f6e1.
https://psnet.ahrq.gov/issue/recognizing-and-managing-errors-cognitive-underspecification
Inc…
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psnet.ahrq.gov/issue/frequency-missed-test-results-and-associated-treatment-delays-highly-computerized-health
July 22, 2009 - Download Citation
Related Resources From the Same Author(s)
Failure to recognize
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psnet.ahrq.gov/issue/making-inpatient-medication-reconciliation-patient-centered-clinically-relevant-and
January 14, 2009 - Patient Safety Innovations
Handshake antimicrobial stewardship as a model to recognize
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psnet.ahrq.gov/issue/comparative-effectiveness-serious-game-and-e-module-support-patient-safety-knowledge-and
September 08, 2010 - September 2, 2020
Incoming interns recognize inadequate physical examination as a cause
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psnet.ahrq.gov/issue/strengths-and-weaknesses-diagnostic-process-endometriosis-patients-perspective-focus-group
March 06, 2019 - April 13, 2022
Handshake antimicrobial stewardship as a model to recognize and prevent
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psnet.ahrq.gov/issue/social-cost-adverse-medical-events-and-what-we-can-do-about-it
February 10, 2015 - Excusable neglect in malpractice suits against radiologists: a proposed jury instruction to recognize
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psnet.ahrq.gov/node/41595/psn-pdf
May 28, 2019 - Luer Connector Misconnections: Under-Recognized but
Potentially Dangerous Events.
May 28, 2019
Medical Product Safety Network. Silver Spring, MD; US Food and Drug Administration. November 19,
2008.
https://psnet.ahrq.gov/issue/luer-connector-misconnections-under-recognized-potentially-dangerous-events
This Web si…
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psnet.ahrq.gov/node/73617/psn-pdf
August 26, 2021 - Recognizing Unsafe Care: What It Is and How to Report It.
August 18, 2021
Patient Safety Foundation. August 26, 2021.
https://psnet.ahrq.gov/issue/recognizing-unsafe-care-what-it-and-how-report-it
This webinar introduced medical error and harm as related concepts to identify unsafe care and enhance
response, engag…
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psnet.ahrq.gov/node/837813/psn-pdf
January 21, 2021 - Recognizing Excellence in Diagnosis.
January 21, 2021
The Leapfrog Group.
https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis
Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise
to be successful. This collaborative initiative will initially dev…
-
psnet.ahrq.gov/node/45021/psn-pdf
April 06, 2016 - Scandal as a sentinel event—recognizing hidden
cost–quality trade-offs.
April 6, 2016
Bloche G. Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. N Engl J Med.
2016;374(11):1001-3. doi:10.1056/NEJMp1502629.
https://psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-t…
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psnet.ahrq.gov/issue/recognizing-our-biases-understanding-evidence-and-responding-equitably-application
April 05, 2023 - Commentary
Recognizing our biases, understanding the evidence, and responding equitably: application of the socioecological model to reduce racial disparities in the NICU.
Citation Text:
McCarty DB. Recognizing our biases, understanding the evidence, and responding equitably: application…
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psnet.ahrq.gov/node/33674/psn-pdf
February 01, 2009 - But
we've come to recognize that some adverse events are at least partly preventable if we do the right … checking the box is supposed to be a proxy for something useful happening in patient care, we have to
recognize … What they do believe, and I
share this belief, is that we have come to recognize that patient safety