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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
April 01, 2006 - Soon, they began to trust me more and more and knew that I would never report them if something went wrong
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psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis
May 26, 2021 - Many endometriosis patients have an intuitive sense that something is desperately wrong as they suffer
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psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - Perspective
Medication Safety in Nursing Homes: What's Wrong
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - A Tale of Two Falls
Citation Text:
Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - Reconciliation
August 5, 2022
WebM&M Cases
Wrong
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psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - What if with deep learning the AI learns something wrong and then applies that mistake to other patients
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psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - What if with deep learning the AI learns something wrong and then applies that mistake to other patients
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psnet.ahrq.gov/perspective/safety-across-board
August 31, 2020 - If we think we got there, then we had our eye on the wrong target to begin with.
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - • This approach isn’t necessarily wrong; clinicians must balance
missing a diagnosis like PE against
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - events concluded that over 75% of all events were attributed to either medication errors involving wrong
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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - Reconciliation
August 5, 2022
WebM&M Cases
Wrong
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - 30, 2019
WebM&M Cases
Slow Down: Right Drug, Wrong
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psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
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/hindsight-2020-thrombolytics-alcohol-intoxication
December 18, 2024 - 2020
WebM&M Cases
Looking for Meds in All the Wrong
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - Reconciliation
August 5, 2022
WebM&M Cases
Wrong
-
psnet.ahrq.gov/node/867428/psn-pdf
December 18, 2024 - patients who had fallen in the hospital
and their family members to understand what they thought went wrong
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - July 8, 2022
WebM&M Cases
Wrong Route for Nutrients
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psnet.ahrq.gov/node/855058/psn-pdf
October 31, 2023 - culture where
people feel psychologically safe working, where they can speak up when things are going wrong
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - the Same Author(s)
WebM&M Cases
Good Night's Sleep Gone Wrong
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psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
November 01, 2005 - industry, keep up with the needs, to shift when we have to shift, and to change when we've done something wrong