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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - Recognizing Injury
Injury from the Veress needle technique may be recognized by using syringe aspiration
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psnet.ahrq.gov/web-mm/monitoring-fetal-health
September 08, 2010 - These abnormalities, which likely would have prompted an urgent cesarean delivery, had not been recognized
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - evaluated by multiple obstetric, medical, and surgical teams, and ultimately the correct diagnosis was
recognized
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psnet.ahrq.gov/node/42769/psn-pdf
November 27, 2013 - Sepsis: recognizing the next event.
November 27, 2013
Kilburn FL, Bailey P, Price D. Sepsis: recognizing the next event. Nursing (Brux). 2013;43(10):14-6.
doi:10.1097/01.NURSE.0000434320.25397.53.
https://psnet.ahrq.gov/issue/sepsis-recognizing-next-event
This commentary describes the development and implementatio…
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psnet.ahrq.gov/node/36678/psn-pdf
August 27, 2007 - Excusable neglect in malpractice suits against
radiologists: a proposed jury instruction to recognize the
human condition.
August 27, 2007
Caldwell C; Seamone ER.
https://psnet.ahrq.gov/issue/excusable-neglect-malpractice-suits-against-radiologists-proposed-jury-
instruction-recognize
The authors discuss the uni…
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psnet.ahrq.gov/node/33669/psn-pdf
May 01, 2018 - Integrating Multiple Medication Decision Support
Systems: How Will We Make It All Work?
May 1, 2018
Peterson JF. Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work?
PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-system…
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psnet.ahrq.gov/node/33830/psn-pdf
March 22, 2016 - Measuring and Responding to Deaths From Medical
Errors
March 22, 2016
Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
Annual Perspective 2016
The Prevalence of Deaths Due to Preventable Adve…
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psnet.ahrq.gov/node/865429/psn-pdf
April 24, 2024 - immediately
The failure to connect the cardioverter/defibrillator to the ECG in this case was not recognized
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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/node/46508/psn-pdf
November 22, 2017 - The checklist: recognize limits, but harness its power.
November 22, 2017
Alspach JAG. The Checklist: Recognize Limits, but Harness Its Power. Crit Care Nurse. 2017;37(5):12-18.
doi:10.4037/ccn2017603.
https://psnet.ahrq.gov/issue/checklist-recognize-limits-harness-its-power
Checklists are used in various health c…
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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…
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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/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/node/49756/psn-pdf
April 01, 2016 - The ward team recognized these clinical changes, yet they had no knowledge of the prior
radiograph findings … First, had the general surgery resident on call formally reviewed the case,
the team may have recognized
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psnet.ahrq.gov/node/49396/psn-pdf
April 01, 2003 - brought all of her pills to the visit, so when the
provider asked to see them, the error was immediately recognized … told that the prescription in this case was “not unduly
messy,” but illegible handwriting is a widely recognized
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psnet.ahrq.gov/web-mm/falling-between-cracks-software
March 09, 2011 - could be avoided with interoperability, inadequate availability of patient information is a widely recognized … Inadequate availability of patient information is a widely recognized problem that results in patient
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psnet.ahrq.gov/node/33695/psn-pdf
April 01, 2010 - technical information to consumers
in a way that is easily understood ("evaluable") is slowly being recognized … time-
efficient consensus process, which will help NQF to achieve the goal of becoming the nationally recognized
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psnet.ahrq.gov/web-mm/picture-speaks-1000-words
July 16, 2015 - Tragically, the limitation of the workaround was only recognized when a single patient presented with … Take-Home Points Workarounds should be recognized as limited, and perhaps dangerous, processes people