sábado, 23 de enero de 2016

Home | AHRQ Patient Safety Network

Home | AHRQ Patient Safety Network

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WebM&M Cases

Commentary by Amy Vogelsmeier, PhD, RN, and Laurel Despins, PhD, RN
Admitted to the hospital for chemotherapy, a man with leukemia and diabetes arrived on the medical unit on a busy afternoon and waited until his room was ready. The nurse who checked him in assumed that his admitting orders were completed on the previous shift. That night, the patient took his own insulin from home without a meal and experienced a preventable episode of hypoglycemia.
Commentary by Robert A. Green, MD, MPH, and Jason Adelman, MD, MS
Presenting to his new primary physician's office for his first visit, a man was checked in under the record of an existing patient with the exact same name and age. The mistake wasn't noticed until the established patient received the new patient's test results by email.
Commentary by Howard I. Maibach, MD
An attending physician recommended using acetic acid to evaluate a lesion on the perineum of a woman who had previously experienced a wart in the same area. The resident physician asked the medical assistant for acetic acid and unknowingly received trichloroacetic acid, which burned the patient's skin.

Perspectives on Safety

Update on Diagnostic Errors


Dr. Graber founded the Society to Improve Diagnosis in Medicine and the journal, Diagnosis. We spoke with him about the recent National Academy of Medicine (formerly Institute of Medicine) Improving Diagnosis in Health Care report, and about diagnostic errors more generally.


Hardeep Singh, MD, MPH
This piece discusses momentum in the field of diagnostic error over the past several years (culminating in the recentImproving Diagnosis in Health Care report) and outlines future avenues to ensure progress in diagnostic safety.

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