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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - WebM&M Cases
Multiple Levels Involved in Prescribing the Wrong
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psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
January 29, 2021 - Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong
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psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
April 01, 2008 - From possible to probable to sure to wrong—premature closure and anchoring in a complicated case.
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - WebM&M Cases
Multiple Levels Involved in Prescribing the Wrong
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psnet.ahrq.gov/sites/default/files/2024-11/spotlight_case_neurological_red_flags_final.pptx
January 01, 2024 - clinicians were correctly identifying patients at higher risk of a vascular event, but then using the wrong … Diagnosing dizziness: we are teaching the wrong paradigm! Acad Emerg Med. 2013;20(10):1064-1066.
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psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
May 16, 2022 - One that I can think of is that with monitors, if you hit the wrong button, it would just shut off instead … have a feature where if it looks like you're about to defibrillate they don't turn off if you hit the wrong
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psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
May 16, 2022 - One that I can think of is that with monitors, if you hit the wrong button, it would just shut off instead … have a feature where if it looks like you're about to defibrillate they don't turn off if you hit the wrong
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psnet.ahrq.gov/web-mm/neurological-red-flags-missed-stroke-after-intermittent-episodes-dizziness-and-headache
February 08, 2023 - clinicians were correctly identifying patients at higher risk of a vascular event, but then using the wrong … Diagnosing dizziness: we are teaching the wrong paradigm!
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psnet.ahrq.gov/node/867206/psn-pdf
December 18, 2024 - clinicians
were correctly identifying patients at higher risk of a vascular event, but then using the wrong … Diagnosing dizziness: we are teaching the wrong paradigm! Acad Emerg Med.
2013;20(10):1064-1066.
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - 1, 2007
WebM&M Cases
Good Night's Sleep Gone Wrong
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psnet.ahrq.gov/node/866578/psn-pdf
August 28, 2024 - setting.5 In a study of 326 pediatric
dose-related safety events from Pennsylvania, 15% involved using wrong
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - December 19, 2014
We know what they did wrong, but not why: the case for 'frame-based
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psnet.ahrq.gov/web-mm/cognitive-overload-icu
June 01, 2005 - WebM&M Cases
Getting the Diagnosis Both Right and Wrong
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - pretend you can look into the
future with your crystal ball and see that your initial diagnosis is wrong
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psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
December 01, 2012 - WebM&M Cases
From Possible to Probable to Sure to Wrong—Premature
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psnet.ahrq.gov/web-mm/privacy-or-safety
December 01, 2011 - The cross-covering resident mixed up the two patients and placed the MRI order in the wrong chart.
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psnet.ahrq.gov/node/60610/psn-pdf
June 24, 2020 - Many endometriosis patients have an intuitive sense
that something is desperately wrong as they suffer
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psnet.ahrq.gov/node/49721/psn-pdf
December 01, 2014 - And
we don't just practice things going right, we practice things going wrong all the time....
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psnet.ahrq.gov/node/33708/psn-pdf
March 01, 2011 - So you really sense that it's a very dynamic process, and things could go wrong at any step.
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psnet.ahrq.gov/node/60856/psn-pdf
August 26, 2020 - including ruling out the worst-case scenario, accepting that the first
assumption or original plan may be wrong