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- Patient Safety Primers 1
- WebM&M Cases 45
- Perspectives on Safety 2
Journal Article
- Commentary 31
- Review 11
- Study 83
- Audiovisual 2
- Book/Report 6
- Newspaper/Magazine Article 26
- Toolkit 1
- Web Resource 4
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Approach to Improving Safety
- Communication Improvement 41
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Education and Training
- Students 6
Error Reporting and Analysis
- Error Analysis 49
- Human Factors Engineering 13
- Legal and Policy Approaches 20
- Logistical Approaches 3
- Quality Improvement Strategies 48
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- Specialization of Care 8
- Teamwork 3
- Technologic Approaches 17
- Transparency and Accountability 1
Safety Target
- Device-related Complications 1
- Diagnostic Errors
- Discontinuities, Gaps, and Hand-Off Problems 22
- Inpatient suicide 1
- Interruptions and distractions 2
Medical Complications
- Delirium 1
- Medication Safety 6
- Nonsurgical Procedural Complications 2
- Overtreatment 2
- Psychological and Social Complications 12
- Second victims 1
- Surgical Complications 8
Setting of Care
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Health Care Providers
- Nurses 10
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Non-Health Care Professionals
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Error Types
- Asia 6
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North America
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Cases & Commentaries
When "Psychiatric" Symptoms Are Not
- Web M&M
Richard J. Goldberg, MD, MS; February 2003
An elderly man with delusions and progressive neurological symptoms initially attributed to psychosis is found to have metastatic cancer.
Cases & Commentaries
Missed Appendicitis
- Spotlight Case
- Web M&M
James G. Adams, MD; June 2003
Abdominal pain misdiagnosed in an ED patient leads to ruptured appendix, multiple complications, and prolonged hospitalization.
Cases & Commentaries
Crushing Chest Pain: A Missed Opportunity
- Spotlight Case
- Web M&M
Mark Graber, MD; January 2004
A patient with chest pain is incorrectly diagnosed as having had an MI. Although physicians eventually realize the patient had an aortic dissection, it is too late. The patient dies.
Cases & Commentaries
Delay in Initiating Antibiotics Results in Fatal Error
- Spotlight Case
- Web M&M
Lisa M. Bellini, MD; February 2004
Housestaff evaluate and admit a severely ill patient with lupus, suspect a viral syndrome, and do not initiate antibiotics. Despite discovery of the correct diagnosis in the morning by the attending, the patient dies.
Cases & Commentaries
Inadvertent Castration
- Web M&M
J. Forrest Calland, MD; January 2004
During a hernia repair, surgeons decide to remove a patient's hydrocele, spermatic cord, and left testiclewithout realizing that his right testicle had been removed previously.
Cases & Commentaries
Autopsy Revelation
- Web M&M
Kaveh G. Shojania, MD; March 2004
A man discharged from the ED is found unresponsive at home the next morning. Autopsy reveals a diagnosis not even considered.
Cases & Commentaries
The Worst Headache
- Web M&M
Jonathan A. Edlow, MD; July 2004
A woman presents with a sudden onset headache, felt to be another migraine. However, when her physician follows up with her by phone, the line goes dead. EMTs find her unconscious.
Cases & Commentaries
Doctor, Don't Treat Thyself
- Web M&M
Elin Olaug Rosvold, MD, PhD; September 2004
An ill physician arrives at the ED for evaluation of shortness of breath. As it is past midnight and he is the only radiologist around, he reads (and misinterprets) his own x-ray.
Cases & Commentaries
Hidden Mystery
- Spotlight Case
- Web M&M
Douglas D. Brunette, MD; March 2005
The challenges of examining and imaging a hospitalized morbidly obese patient delay diagnosis, threatening the patient's life.
Cases & Commentaries
Pregnant With Danger
- Web M&M
Mark D. Pearlman, MD; Jeffrey S. Desmond, MD; May 2005
A woman who was 38 weeks pregnant came to the emergency department (ED) complaining of left leg pain. Ruled out for deep vein thrombosis, she was sent home, only to die the following morning.
Cases & Commentaries
Lost in Transition
- Spotlight Case
- Web M&M
Christopher Beach, MD; February 2006
A woman comes to the ED with mental status changes. Although numerous tests are run and she is admitted, a critical test result fails to reach the medicine team in time to save the patient's life.
Cases & Commentaries
An Outpatient 'Zebra'
- Web M&M
Lee Berkowitz, MD; January 2006
Over several weeks, a man with left foot pain and numbness is evaluated by numerous doctors, each resident and attending pair offering a different incorrect diagnosis until the patient's fourth visit.
Cases & Commentaries
The "Customer" Is Always Right
- Spotlight Case
- Web M&M
Niraj L. Sehgal, MD, MPH; February 2007
A parent brings her 18-month-old into the clinic with multiple complaints, including rash, diarrhea, and concern for fracture due to a fall. The child is sent home with a diagnosis of viral syndrome. Later, still concerned about her child's gait, the mother takes her to the ED, where an x-ray reveals a fractured tibia.
Cases & Commentaries
Rapid Mis-St(r)ep
- Web M&M
Edward L. Kaplan, MD; February 2007
In the urgent care clinic, a 5-year-old with fever and sore throat undergoes a rapid strep test, which is negative. Later, the child seems worse, and the father takes her to the ED, where another rapid strep test is strongly positive for group A streptococcal infection.
Cases & Commentaries
Dependence vs. Pain
- Spotlight Case
- Web M&M
Adam J. Gordon, MD, MPH; July 2008
A man with a history of heroin use came to the hospital with abdominal pain, nausea, and vomiting. Admitted for dehydration and opiate withdrawal, he was given intravenous fluids, methadone, and morphine for abdominal pain. The patient complained of worsening pain overnight and was given more methadone. In the morning, the patient had more severe pain and tachycardia, and was found to have a perforated colon.
Cases & Commentaries
Failure to Latch
- Web M&M
Mitch Rodriguez, MD, MBA; Rebecca Mannel, BS, IBCLC; Donna Frye, RN, MN; September 2008
After several pediatric visits, parents of a newborn with low output and weight loss contact a lactation consultant, who discovered that ankyloglossia (tongue-tie) was preventing the infant from receiving adequate intake from breastfeeding.
Cases & Commentaries
Coming Up Short
- Web M&M
Ze'ev Hochberg, MD, PhD; October 2008
Well-child checks failed to determine that the growth of a young immigrant girl was severely behind the curve. At the age of 12, routine lab tests showed a TSH of 834—indicating severe hypothyroidism.
Cases & Commentaries
Delirium or Dementia?
- Spotlight Case
- Web M&M
James L. Rudolph, MD, SM; May 2009
An elderly woman hospitalized for pneumonia becomes disoriented during hospitalization. Even though the patient was never confused at baseline, doctors attribute it to "senile dementia" and place her in restraints.
Cases & Commentaries
Hiding in Plain Sight
- Web M&M
Jeffrey M. Weinberg, MD ; August2009
One day after being discharged from the ED, a woman with severe back pain returns and is admitted for observation and analgesics. The next morning, the hospitalist notes a vesicular rash in the exact distribution of the patient's pain symptoms and diagnoses a herpes zoster infection (shingles).
Cases & Commentaries
Missing Trauma
- Web M&M
Gregory J. Jurkovich, MD; May 2009
After an hour of failed resuscitative efforts, a woman who collapsed in a market is pronounced dead in the emergency department (ED). Only later do the paramedics and physician discover a small bullet in the patient's chest.
Cases & Commentaries
Adolescent Diabetes: A Routine Visit?
- Spotlight Case
- Web M&M
Gail B. Slap, MD, MSc; February 2010
An overweight teenaged girl came to the pediatrics clinic for routine follow-up of her type 2 diabetes, complaining of nonspecific, intermittent abdominal pain and worsening acne. The physician prescribed topical acne cream and increased her diabetes medications. The next day, an obstetrician notified the pediatrician that this patient had delivered a healthy infant via Caesarian section overnight.
Cases & Commentaries
Acute Respiratory Arrest in Pregnancy
- Web M&M
Baha Sibai, MD; June 2010
A woman with chronic hypertension developed undiagnosed preeclampsia during pregnancy with twins. At 38 weeks, she experienced respiratory and cardiac arrest. Although she eventually recovered, the infants were stillborn.
Cases & Commentaries
Paradoxical Pulse
- Web M&M
Christopher Roy, MD; February 2011
A week after successful pacemaker placement, an elderly man developed chest pain and was admitted to the hospital without having an urgent echocardiogram. Although providers felt that he "looked fine," the patient became acutely hypotensive, developed ventricular tachycardia and pulseless electrical activity, and required emergent resuscitative measures for cardiac tamponade.
Cases & Commentaries
Missing the Point—Eye Injury
- Web M&M
Rahul Sharma, MD, MBA; and Douglas Brunette, MD, MPH; December 2011
A woman presented to the emergency department with an eyelid laceration, which was sutured without complication. Her visual acuity was not formally tested and ophthalmology was not consulted. Ten days later, she presented with eye pain and poor vision. Ophthalmologist evaluation revealed a ruptured globe requiring surgical repair.
Cases & Commentaries
Cultural Dimensions of Depression
- Web M&M
J. David Kinzie, MD; March 2012
Admitted to the hospital complaining of difficulty breathing and swallowing, a Vietnamese man was diagnosed with reflux disease and an outpouching of the esophagus. The patient was anxious and repeatedly stated that he was "dying" from his physical ailments. During a gastroenterology consultation, the patient ran to the restroom and jumped out the window, killing himself.
Cases & Commentaries
Misleading Complaint
- Web M&M
Krishan Soni, MD, MBA, and Gurpreet Dhaliwal, MD; July 2012
A man presented to the emergency department (ED) complaining of knee problems, and the triage nurse wrote down the chief complaint as "bilateral knee pain." The ED physician diagnosed a musculoskeletal injury and prepared to discharge him, but the patient was noticeably unsteady. Further examination and imaging revealed a subdural hematoma requiring urgent neurosurgical intervention.
Cases & Commentaries
A Real Heartache
- Web M&M
Steven K. Polevoi, MD; December 2012
Following an emergency department (ED) evaluation for chest pain, a patient was discharged with a presumptive diagnosis of gastroesophageal reflux disease. Two days later, he returned to the ED in severe distress, now with an acute myocardial infarction and a large pericardial effusion.
Cases & Commentaries
Missed Pneumonia
- Web M&M
Jeffrey M. Rohde, MD, and Scott A. Flanders, MD; November 2012
A 32-year-old man went to the emergency department with fever and pleuritic chest pain. Following an extensive work-up, he was discharged with "fever, pleural effusion, and chest wall pain", but no clear diagnosis. He returned to the ED 3 days later with worsening pain, continued fever, a new cough, and dyspnea. The patient was started on antibiotics and admitted for pneumonia with effusion.
Cases & Commentaries
From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case
- Web M&M
David E. Newman-Toker, MD, PhD; April 2013
Admitted to the hospital with headache and word-finding difficulties, a man was given a preliminary diagnosis of vasculitis. Although serial imaging studies seemed to indicate progression of his brain lesions, these were not biopsied and discovered to be glioblastoma multiforme until 4 months later. The delay in diagnosis contributed to his rapid clinical decline.
Cases & Commentaries
It's Sarah, Not Stephen!
- Spotlight Case
- Web M&M
Urmimala Sarkar, MD, MPH; October 2013
Although the mother of a child, born male who identified as and expressed externally as a girl, had alerted the clinic of the child's preferred name when making the appointment, the medical staff called for the patient in the waiting room using her legal (masculine) name.
Cases & Commentaries
Emergency Error
- Spotlight Case
- Web M&M
Nicholas Symons, MBChB, MSc; July-August 2013
An elderly woman with severe abdominal pain was admitted for an emergency laparotomy for presumed small bowel obstruction. Shortly after induction of anesthesia, her heart stopped. She was resuscitated and transferred to the intensive care unit, where she died the next morning. The review committee felt this case represented a diagnostic error, which led to unnecessary surgery and a preventable death.
Cases & Commentaries
Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients
- Web M&M
Jonathan P. Piccini, MD, MHS; L. Kristin Newby, MD, MHS; and Robert M. Califf, MD; February 2014
A woman with coronary artery disease, diabetes, and hypertension was admitted for a myocardial infarction. Following percutaneous coronary intervention, the patient had several runs of non-sustained ventricular tachycardia (NSVT) and later experienced a cardiac arrest secondary to sustained VT.
Cases & Commentaries
Pitfalls in Diagnosing Necrotizing Fasciitis
- Spotlight Case
- Web M&M
Terence Goh, MBBS, and Lee Gan Goh, MBBS; July-August 2014
Admitted with bruising from a fall and persistent pain on his left side, a patient was kept in the emergency department overnight due to crowding. After being reevaluated by the surgical service the next day, the patient was urgently taken to the operating room for probable necrotizing fasciitis and pyomysitis.
Cases & Commentaries
Dissecting the Presentation
- Spotlight Case
- Web M&M
Shirley Beng Suat Ooi, MBBS (S'pore); April 2015
A woman admitted to the hospital with a presumed transient ischemic attack and possible gastrointestinal bleeding was found unconscious and in cardiac arrest on hospital day 2. Despite maximal resuscitation efforts, the patient died. Autopsy revealed that the cause of death was an acute aortic dissection.
Cases & Commentaries
Abdominal Pain in Early Pregnancy
- Spotlight Case
- Web M&M
Charlie C. Kilpatrick, MD; September 2015
After several days of abdominal pain, nausea, and vomiting, a pregnant woman visited the emergency department and was swiftly discharged with antibiotics for a UTI. However, she returned the next day with unchanged abdominal pain and more nausea and vomiting. Apart from a focused ultrasound to document her pregnancy, no further testing was done. The patient again returned the following day with increased pain and now appeared more ill. An MRI revealed a ruptured appendix.
Cases & Commentaries
Communication With Consultants
- Web M&M
Steven L. Cohn, MD; June 2016
When a pregnant woman with fever, nausea, and headaches presented to the emergency department (ED), laboratory tests showed an incredibly high white blood cell count. Although the ED contacted the hematology service for a consultation, the urgency of the patient's clinical status was not conveyed, leading to a fatal delay in diagnosing and treating her acute myeloid leukemia.
Cases & Commentaries
Diagnosing a Missed Diagnosis
- Web M&M
James B. Reilly, MD, MS, and Christopher Webster, DO; March 2017
A woman taking modified-release lithium for bipolar disorder was admitted with cough, slurred speech, confusion, and disorientation. Diagnosed with delirium attributed to hypercalcemia, she was treated with aggressive hydration. She remained disoriented and eventually became comatose. After transfer to the ICU, she was diagnosed with nephrogenic diabetes insipidus due to lithium toxicity.
Cases & Commentaries
Shortcuts to Acetaminophen-induced Liver Failure
- Web M&M
Stephen Bacak, DO, MPH, and Loralei Thornburg, MD; March 2018
A pregnant woman presented to the emergency department 3 times in 4 days, first with symptoms of upper respiratory infection, nausea, and fever; then abdominal cramps; then shortness of breath and abdominal pain. On the third visit, she was diagnosed with influenza and possible sepsis. In between visits, the patient had been taking acetaminophen (1g every 4 hours) to control her fever. Although she had signs of acute fulminant hepatitis due to acetaminophen overdose, administration of the antidote, N-acetylcysteine, was delayed for 10 hours.
Cases & Commentaries
Missing ECG and Missed Diagnosis Lead to Dangerous Delay
- Web M&M
Robert E. O'Connor, MD, MPH; March 2018
Emergency medical service (EMS) providers obtained an electrocardiogram (ECG) in a woman who had developed severe chest pressure at home. The ECG revealed an ST-elevation myocardial infarction (STEMI). Unfortunately, the ECG failed to transmit to the emergency department (ED) while EMS was en route, so a "Code STEMI" was not activated. Unaware of the original ECG results, ED clinicians obtained a repeat ECG that did not demonstrate the earlier ST segment elevations, and the patient was admitted to the telemetry unit for monitoring overnight. The next morning, lab results revealed an elevated troponin level and another ECG demonstrated she had a large heart attack the previous day. Although the patient was rushed to the cardiac catheterization laboratory, the delay in treatment led to significant loss of cardiac function.
Cases & Commentaries
Perils in Diagnosing a Stroke
- Web M&M
Joseph L. Schindler, MD; June 2018
Brought to the emergency department after being found unresponsive, an older man was given systemic thrombolytics to treat a suspected stroke. After administering the medication, the nurse noticed patches on the patient's back. The patient's wife explained that the patches, which contained fentanyl and whose doses had recently been increased, were for chronic back pain. In fact, the wife had placed two patches that morning. Medication reconciliation revealed that the patient had inadvertently received 3 times his previous dose. He was administered naloxone to treat the opioid overdose. Although he became more responsive, he had a generalized seizure and a CT showed intracranial hemorrhage—an adverse consequence of the thrombolytics.
Cases & Commentaries
Abdominal Aortic Aneurysm Screening
- Spotlight Case
- Web M&M
Jeffrey Jim, MD, MPHS; August 2018
An older man with multiple medical conditions and an extensive smoking history was admitted to the hospital with worsening shortness of breath. He underwent transthoracic echocardiogram, which demonstrated severe aortic stenosis. The cardiology team recommended cardiac catheterization, but the interventional cardiologist could not advance the catheter and an aortogram revealed an abdominal aortic aneurysm (AAA) measuring 9 cm in diameter. Despite annual visits to his primary care physician, he had never undergone screening ultrasound to assess for presence of an AAA. The patient was sent emergently for surgical repair but had a complicated surgical course.
Cases & Commentaries
Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis
- Spotlight Case
- Web M&M
Ifedayo Kuye, MD, MBA, and Chanu Rhee, MD, MPH; October 2018
Admitted with generalized weakness, nausea, and low blood pressure, an elderly man was given IV fluids and broad spectrum antibiotics. Laboratory test results revealed a mildly elevated white count, acute kidney injury, and elevated liver function tests. The patient was admitted to the medical ICU with a presumed diagnosis of septic shock. His blood pressure continued to trend downward. While reviewing the emergency department test results, the ICU resident noticed the patient's troponin level was markedly elevated and his initial ECG revealed T-wave inversions. A repeat ECG in the ICU showed obvious ST segment elevations, diagnostic of an acute myocardial infarction. The resident realized that the patient's low blood pressure was likely due to the myocardial infarction, not septic shock. He underwent urgent cardiac catheterization and was found to have complete occlusion of the right coronary artery, for which a stent was placed.
Cases & Commentaries
Spotlight: Mistaken Attribution, Diagnostic Misstep
- Spotlight Case
- Web M&M
Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD; January 2019
A woman with a history of psychiatric illness presented to the emergency department with agitation, hallucinations, tachycardia, and transient hypoxia. The consulting psychiatric resident attributed the tachycardia and hypoxia to her underlying agitation and admitted her to an inpatient psychiatric facility. Over the next few days, her tachycardia persisted and continued to be attributed to her psychiatric disease. On hospital day 5, the patient was found unresponsive and febrile, with worsening tachycardia, tachypnea, and hypoxia; she had diffuse myoclonus and increased muscle tone. She was transferred to the ICU of the hospital, where a chest CT scan revealed bilateral pulmonary emboli (explaining the tachycardia and hypoxia), and clinicians also diagnosed neuroleptic malignant syndrome (a rare and life-threatening reaction to some psychiatric medications).
Cases & Commentaries
Diagnostic Failure: The Growing Deficit
- Web M&M
Robert Chang, MD, and Scott Flanders, MD; February 2019
A woman was admitted to a hospital's telemetry floor for management of uncontrolled hypertension and palpitations. On the first hospital day, she complained of right arm numbness and weakness and had new difficulty answering questions. The nurse called the hospitalist and relayed the arm symptoms, but not the word-finding difficulty. The hospitalist asked the nurse to call for a neurology consultation. Four hours later, the patient's weakness had progressed; she was now completely unable to move her right arm. At that point, neither the hospitalist nor the neurology consultant had evaluated the patient in person. A stat head CT revealed a large ischemic stroke.
Cases & Commentaries
Spinal Epidural Abscess
- Web M&M
Yi Lu, MD, PhD, and Douglas Salvador, MD, MPH; August 2019
A woman with a history of prior spine surgery presented to the emergency department with progressive low back pain. An MRI scan of T11–S1 showed lumbar degenerative joint disease and a small L5–S1 disc herniation. She was referred for physical therapy and prescribed muscle relaxant, non-steroidal anti-inflammatories, and pain relievers. Ten days later, she presented to a community hospital with fever, inability to walk, and numbness from the waist down. Her white blood cell count was greater than 30,000 and she was found to be in acute renal and liver failure. She was transferred to a neurosurgery service at an academic hospital when an MRI revealed a T6–T10 thoracic epidural abscess.
Perspectives on Safety > Perspective
The Evidence-Based Physical Examination as a Patient Safety Practice
with commentary by Steven McGee, MD, The Demise of the Physical Exam, November 2012
This piece details the benefits of an evidenced-based approach to physical examination and diagnosis.
Perspectives on Safety > Interview
In Conversation With… Abraham Verghese, MD
The Demise of the Physical Exam, November 2012
A passionate advocate for the importance of the physical exam, Dr. Verghese is a Professor at Stanford University School of Medicine and a bestselling author.
Patient Safety Primers
Diagnostic Errors
Thousands of patients die every year due to diagnostic errors. While clinicians' cognitive biases play a role in many diagnostic errors, underlying health care system problems also contribute to missed and delayed diagnoses.
Journal Article > Review
Changes in rates of autopsy-detected diagnostic errors over time: a systematic review.
- Classic
Shojania KG, Burton EC, McDonald KM, Goldman L. JAMA. 2003;289:2849-2856.
A systematic review of the literature from 1966 to 2002 was performed to determine the rate at which autopsies detect important, clinically missed diagnoses and the extent to which this rate has changed over time. Fifty-three autopsy series were studied that reported diagnoses involving a primary cause of death (major errors) and those likely to have affected patient outcome (class I errors). The median major error rate was 23.5% (4.1% to 49.8%), and the median class I error rate was 9.0%. Over time, there were relative decreases in major errors and class I errors of 19.4% and 33.4% per decade, respectively. Despite these decreases, the authors estimate that for modern U.S. institutions, there is likely a major error rate from 8.4% to 24.4% and a class I error rate from 4.1% to 6.7%.
Journal Article > Study
Fixing broken bones and broken homes: domestic violence as a patient safety issue.
Cohn F, Rudman WJ. Jt Comm J Qual Saf. 2004;30:636-646.
Journal Article > Commentary
Improving patient care. The cognitive psychology of missed diagnoses.
Redelmeier DA. Ann Intern Med. 2005;142:115-120.
This case study describes the events surrounding a series of diagnostic errors in a patient initially treated for pharyngitis and ultimately diagnosed with an epidural abscess and osteomyelitis. While reviewing the details of the case, the author explores the pitfalls leading to missed diagnoses, including several types of "cognitive shortcuts" that commonly lead to such errors. Discussion offers strategies to overcome these diagnostic shortcomings and methods to combat natural cognitive tendencies. This article is part of a special collection entitled ''Quality Grand Rounds,'' a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors.
Journal Article > Commentary
Surgical accountability in the 1880s: the death of Susan Nixon.
Watters GR, Walker DR. ANZ J Surg. 2005;75:719-722.
Using an account of surgical error from nineteenth-century Australia, the authors draw parallels with how medical mistakes and accountability are discussed today.
Journal Article > Study
Clinical impact and frequency of anatomic pathology errors in cancer diagnoses.
- Classic
Raab SS, Grzybicki DM, Janosky JE, et al. Cancer. 2005;104:2205-2213.
This AHRQ-funded study estimated a 12% error rate in cancer diagnosis based on discrepant evaluation of two specimens from the same organ. Investigators compiled web-based pathologic data from four institutions and created a standardized system to establish correlation error frequencies between cytologic and histologic samples during a 6-month period (eg, bronchial washings and a lung biopsy). Findings suggested that error rates were dependent on the institution and an association existed between the institution and error cause, but agreement was lacking on whether these errors resulted from misinterpretation or poor clinical sampling. Disagreement also existed on the clinical significance of the errors, an issue that results from an undeveloped taxonomy in this arena. While a previous systematic review used autopsy findings to report on clinically significant errors, this study builds on that literature by employing a method that is not limited by the overall low rate of autopsies performed nationally.
Journal Article > Study
Iatrogenic harm caused by diagnostic errors in fibrodysplasia ossificans progressiva.
Kitterman JA, Kantanie S, Rocke DM, Kaplan FS. Pediatrics. 2005;116:e654-e661.
The authors studied diagnostic errors for a rare genetic disease and found that misdiagnoses and unnecessary medical procedures resulted from failures in information transfer.
Journal Article > Study
Overestimation of clinical diagnostic performance caused by low necropsy rates.
Shojania KG, Burton EC, McDonald KM, Goldman L. Qual Saf Health Care. 2005;14:408-413.
Assessing how well clinicians or diagnostic tests perform in detecting a given condition depends on knowing the number of correctly diagnosed cases and missed diagnoses. Combining their previous work with published studies of diagnostic performance for aortic dissection, pulmonary embolism, and tuberculosis, the authors show that adjusting for missed diagnoses among non-autopsied deaths lowers diagnostic performance. They estimate that 17% of patients with tuberculosis, 18% to 26% with aortic dissection, and 9% with pulmonary embolism die without clinicians considering the possibility of those diagnoses. All of these findings fall significantly below the previously reported rates. The authors point out that many missed diagnoses may represent limitations of current technology or atypical presentations of these conditions rather than errors. Nonetheless, clinically significant diagnoses escape detection at a greater rate than is generally appreciated.
Newspaper/Magazine Article
Why doctors so often get it wrong.
Leonhardt D. New York Times. February 22, 2006;Business section:1.
This article reports on misdiagnosis and strategies that some health care organizations are using to improve accuracy.
Newspaper/Magazine Article
Confronting a colleague who covers up a medical error.
Brody H. Am Fam Physician. 2006;73:1272, 1274.
This article presents a case scenario of an unacknowledged misdiagnosis discovered through a patient's request for a second opinion. The author discusses how the colleague who discovered the mistake should address the first physician's denial of error.
Journal Article > Study
The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer.
Raab SS, Meier FA, Zarbo RJ, et al. J Clin Oncol. 2006;24:2808-2814.
The AHRQ–funded researchers analyzed false-negative diagnostic results and found poor agreement among pathologists as to the causes of the error. The authors conclude that pathologist reluctance to change or challenge a peer's reading is a contributing factor.
Journal Article > Study
Direct reporting of laboratory test results to patients by mail to enhance patient safety.
Sung S, Forman-Hoffman V, Wilson MC, Cram P. J Gen Intern Med. 2006;21:1075-78.
The investigators surveyed primary care physicians regarding direct notification of results for three specific diagnostic tests. They found that physicians generally favored direct reporting to patients when test results were normal, had less diagnostic severity, or had less potential for emotional impact.
Journal Article > Commentary
Language barriers to health care in the United States.
Flores G. N Engl J Med. 2006;355:229-231.
The author discusses how language barriers can compromise a patient's health care and highlights the need for reliable interpreters to communicate medical information.
Journal Article > Study
Delayed or missed diagnosis of cervical spine injuries.
Platzer P, Hauswirth N, Jaindl M, Chatwani S, Vecsei V, Gaebler C. J Trauma. 2006;61:150-155.
The authors found that misinterpretations, incomplete information, inadequate radiographs, or lack of physician radiograph review contributed to problematic diagnoses of cervical spine injuries.
Journal Article > Study
Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims.
- Classic
Gandhi TK, Kachalia A, Thomas EJ, et al. Ann Intern Med. 2006;145:488-496.
Medical errors in the outpatient setting have remained a relatively understudied aspect of patient safety. This study analyzed data from malpractice claims at four liability insurers, similar to companion studies of errors in surgical and emergency department patients, to determine the frequency and causes of missed and delayed diagnoses. Diagnostic errors resulting in patient harm occurred in 181 cases, chiefly consisting of missed or delayed diagnoses of cancer. Failure to reach a timely diagnosis was generally due to multiple process breakdowns, including failure to order an appropriate diagnostic test and inadequate follow-up planning, many of which could be ascribed to physician cognitive errors. As with prior studies using chart review, reviewer's agreement on whether an error occurred was only moderate. The authors note that due to the complexity of contributing factors to outpatient errors, simple solutions are unlikely. An accompanying editorial, available via the link below, considers the differences in the nature of errors and approaches to solving them between the inpatient and outpatient settings and calls for greater attention to tackling outpatient safety issues.
Journal Article > Study
Inappropriate surgeries resulting from misdiagnosis of early amyotrophic lateral sclerosis.
Srinivasan J, Scala S, Jones HR, Saleh F, Russell JA. Muscle Nerve. 2006;34:359-360.
The investigators analyzed medical records of patients with amyotrophic lateral sclerosis (ALS). They discovered that, prior to diagnosis, some patients had surgery for issues that in retrospect were signs of early ALS.
Newspaper/Magazine Article
When a heart attack goes undiagnosed.
Davis R. USA Today. October 25, 2006.
This article shares stories of missed heart attack diagnoses and is accompanied by an online poll for readers to share their experiences with medical error.
Journal Article > Commentary
A medical error leads to tragedy: how do we inform the patient?
Baumrucker SJ. Am J Hosp Palliat Care. 2006;23:417-421.
This roundtable discussion provides legal, ethical, nursing, and medical perspectives on whether to disclose a misdiagnosis to the patient and their family after cancer has metastasized and death is imminent.
Newspaper/Magazine Article
Preventing the tragedy of misdiagnosis.
Landro L. Wall Street Journal (Eastern edition). November 29, 2006: D1-D5. [Reprinted on Post-gazette.com].
This article describes a decision support program used by Kaiser Permanente and U.S. Veterans Administration to help minimize misdiagnosis.
Why Current Breast Pathology Practices Must Be Evaluated.
Dallas, TX: Susan G. Komen Breast Cancer Foundation; June 2006.
This report illustrates weaknesses in current pathology practice of breast cancer diagnosis and suggests improvements for reliability and effectiveness.
Journal Article > Study
Diagnostic pitfalls in paediatric ischaemic stroke.
Braun KP, Kappelle LJ, Kirkham FJ, Deveber G. Dev Med Child Neurol. 2006;48:985-990.
The researchers analyzed case histories of children affected by stroke and found the condition was frequently not initially recognized as the cause of symptoms. They suggest that specialized centers familiar with pediatric stroke and standardized diagnostic procedures should be used.
Newspaper/Magazine Article
Software for symptoms.
Borzo J. Wall Street Journal. May 23, 2005:R10.
This article discusses decision support system implementation and use, and its role in preventing physician misdiagnosis.
Newspaper/Magazine Article
What's the trouble? How doctors think.
Groopman J. The New Yorker. January 29, 2007;47:36-41.
The author discusses how heuristics can lead to errors in physician judgement and decision making.
Journal Article > Study
Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians.
Davidenko JM, Snyder LS. J Electrocardiol. 2007;40:450-457.
Prior research on diagnostic errors related to inaccurate interpretation of electrocardiograms (ECGs) has generally focused on identification of acute myocardial infarction. In this cohort study, cardiologists re-reviewed ECGs to identify the rate of false-positive and false-negative diagnoses of atrial fibrillation, the most common cardiac arrhythmia. Both false-positive and false-negative diagnoses were relatively common, especially in patients with ventricular pacemakers. The authors identified several common errors in interpretation, both by human readers and the computerized interpretation. A prior study also found that the computerized ECG interpretation frequently did not identify the correct cardiac rhythm.
Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.
Baker M. Manchester, England: NHS North West; February 2007.
This report shares findings from an investigation into individual and system failures that contributed to a radiologist misreading mammograms for a 2-year period.
Journal Article > Study
Missed diagnoses by urologists resulting in malpractice payment.
Badger WJ, Moran ME, Abraham C, Yarlagadda B, Perrotti M. J Urol. 2007;178;2537-2539.
This study discovered that more than 25% of indemnity payments from closed malpractice claims resulted from missed or delayed diagnoses.
The Rebecca O'Malley Report.
Cork, Ireland: Health Information and Quality Authority; March 21, 2008.
This report analyzes the findings of a diagnostic error investigation and provides numerous recommendations to improve standards for treating symptomatic breast disease.
Journal Article > Study
Diagnostic errors and temporal stability in bipolar disorder.
López J, Baca E, Botillo C, et al. Actas Esp Psiquiatr. 2008;36:205-209.
This study examined diagnostic errors during the initial course of bipolar disease and discovered low rates of diagnostic accuracy at initial presentation and low rates of those maintaining the diagnosis.
Journal Article > Study
Quality of clinical aspects of call handling at Dutch out of hours centres: cross sectional national study.
Derkx HP, Rethans JE, Muijtjens AM, et al. BMJ. 2008;337:a1264.
Inadequate telephone triage of patients' complaints has been recognized as a patient safety issue. This detailed study using simulated patients found that triage personnel frequently failed to ask recommended questions and also failed to provide appropriate self-care advice.
Journal Article > Review
The impact of declining clinical autopsy: need for revised healthcare policy.
Xiao J, Krueger GR, Buja LM, Covinsky M. Am J Med Sci. 2009;337:41-46.
This review discusses how autopsy rates for patients are at an all-time low, while major errors in clinical diagnoses have increased. The authors advocate for a change in policies concerning autopsies.
Journal Article > Study
The impact of clinically undiagnosed injuries on survival estimates.
Gedeborg R, Thiblin I, Byberg L, Wernroth L, Michaëlsson K. Crit Care Med. 2009;37:449-455.
The continuing decline in the performance of autopsies has led to considerable concern that physicians are increasingly unaware of diagnostic errors. Missed diagnoses may also adversely affect the accuracy of prognostic systems. This Swedish study compared hospital discharge data and autopsy data for trauma patients and found that missed injuries were relatively common despite an autopsy rate of less than 25%. The performance of the International Classification of Diseases Injury Severity Score—a commonly used prognostic tool for trauma patients—could have been improved by incorporating autopsy data. As in prior studies, the authors conclude that maintaining a high autopsy rate is essential to improving the accuracy of clinical diagnoses.
Journal Article > Study
Preventable morbidity at a mature trauma center.
Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.
Patient safety in trauma poses unique challenges given the acuity of the patients and the need for rapid assessment in delivering life-saving care. This study analyzed more than 2500 complications discussed at morbidity and mortality (M&M) conferences to characterize their preventability and clinical relevance. Investigators discovered that the complications ripe for quality improvement initiatives included unintended extubations, surgical technical failures, missed injuries, and intravascular catheter-related complications. An invited critique [see link below] reflects on the study's findings and points out the challenges in reporting performance data without needed standardization. A past AHRQ WebM&M commentary discussed the systematic assessment of trauma patients in the context of a missed patient injury.
Journal Article > Study
Misleading one detail: a preventable mode of diagnostic error?
Arzy S, Brezis M, Khoury S, Simon SR, Ben-Hur T. J Eval Clin Pract. 2009;15:804-806.
Diagnostic errors frequently occur because of cognitive errors on the part of physicians. This study used case vignettes to vividly illustrate one specific cognitive error, the "framing effect," whereby a clinician places undue emphasis on a single (often extraneous) piece of information. Inclusion of a single misleading detail resulted in experienced clinicians making significantly more diagnostic errors. The process of meta-cognition, or "thinking about thinking," is often used to attempt to overcome this and other biases in clinical decision-making. An AHRQ WebM&M perspective explores issues related to cognitive errors in diagnosis.
Journal Article > Study
Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis.
Singh H, Daci K, Petersen LA, et al. Am J Gastroenterol. 2009;104:2543-2554.
This study identified process breakdowns, including failure to follow up on abnormal test results, as missed opportunities for prevention in colorectal cancer screening and evaluation.
Journal Article > Study
Characteristics and predictors of missed opportunities in lung cancer diagnosis: an electronic health record-based study.
Singh H, Hirani K, Kadiyala H, et al. J Clin Oncol. 2010;28:3307-3315.
Journal Article > Study
Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis.
Eva KW, Link CL, Lutfey KE, McKinlay JB. Acad Med. 2010;85:1112-1117.
This study found that clinical experience was the most important factor in retaining diagnostic flexibility and avoiding premature closure with an incorrect diagnosis.
Journal Article > Study
To think is good: querying an initial hypothesis reduces diagnostic error in medical students.
Coderre S, Wright B, McLaughlin K. Acad Med. 2010;85:1125-1129.
This study found that questioning an initial diagnosis often led students to rectify an incorrect one. The authors suggest that formal querying may serve as a tool to reduce diagnostic errors.
Journal Article > Study
Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents.
- Classic
Mamede S, van Gog T, van den Berge K, et al. JAMA. 2010;304:1198-1203.
Diagnostic errors are frequently ascribed to cognitive errors on the part of clinicians. Prominent among these is availability bias, when clinicians choose the most available diagnosis—the first that comes to mind—when faced with a complex diagnostic scenario. In this Dutch study, internal medicine residents were presented with a series of diagnosed cases, then given cases with similar symptoms and asked to record their provisional diagnoses. The investigators did find evidence of availability bias, but also found that asking residents to reflect on their diagnostic process mitigated the effects of availability bias. Diagnostic errors have been termed the next frontier in patient safety, and an AHRQ WebM&M commentary discusses reflective practice and other methods of avoiding cognitive error in diagnosis.
Journal Article > Study
Comparison of the clinical diagnosis and subsequent autopsy findings in medical malpractice.
Pakis I, Polat O, Yayci N, Karapirli M. Am J Forensic Med Pathol. 2010;31:218-221.
This study from Turkey confirms the utility of autopsies in identifying diagnostic errors, as there was discordance between the clinical and pathologic diagnoses in 13.8% of cases.
Sepsis Emergency.
Tampa, FL: Sepsis Alliance; 2010.
Revealing incidents in which diagnostic delay led to sepsis, this video provides information to help consumers recognize the condition.
Journal Article > Commentary
Checklists to reduce diagnostic errors.
Ely JW, Graber ML, Croskerry P. Acad Med. 2011;86:307-313.
Diagnostic errors are rapidly gaining attention as the next frontier in patient safety, driven by studies of their incidence in malpractice claims and autopsy reports. On the other hand, checklists have become popularized in health care as a tool to promote safe practices. This commentary explores the application of checklists to the diagnostic process. The authors suggest three types of checklists: a general one that prompts providers to optimize their cognitive approach, a differential diagnosis checklist to ensure correct diagnoses are considered, and a checklist of common pitfalls and cognitive forcing functions to improve evaluation of certain diseases. Specific examples of checklists are provided with a discussion of future directions to study their adoption and impact. A past AHRQ WebM&M perspective and interview discussed diagnostic errors in medicine.
Journal Article > Study
Patient safety in out-of-hours primary care: a review of patient records.
Smits M, Huibers L, Kerssemeijer B, de Feijter E, Wensing M, Giesen P. BMC Health Serv Res. 2010;10:335.
This study found a low rate of patient safety incidents involving telephone care interactions. Most incidents were related to failures in clinical reasoning. A past AHRQ WebM&M commentary discussed potential pitfalls in providing medical advice by telephone.
Journal Article > Study
Role of clinical context in residents' physical examination diagnostic accuracy.
Sibbald M, Panisko D, Cavalcanti RB. Med Educ. 2011;45:415-421.
Providing a brief clinical scenario increased internal medicine residents' diagnostic accuracy for cardiac valvular lesions, although, interestingly, their ability to identify specific physical examination findings did not change. The authors hypothesize that knowledge of the clinical scenario simply led residents to generate heuristics, which could actually increase the risk of diagnostic error.
Newspaper/Magazine Article
Medical mystery: alcoholism didn't cause man's diabetes and cirrhosis.
Boodman SG. Washington Post. June 13, 2011:E1.
This newspaper article reveals how biases and lack of trust in the patient/family perspective may contribute to diagnostic error.
Journal Article > Commentary
Skin-deep diagnosis: affective bias and zebra retreat complicating the diagnosis of systemic sclerosis.
Miller CS. Am J Med Sci. 2013;345:53-56.
Analyzing a case that resulted in delayed diagnosis of an uncommon condition, this commentary discusses how cognitive biases can affect clinical decision making.
Journal Article > Commentary
Why do GDPs fail to recognise oral cancer? The argument for an oral cancer checklist.
Dave B. Br Dent J. 2013;214:223-225.
This commentary explores causes for delayed diagnoses of oral cancers in general dental care and recommends improved training, ongoing continuing professional development, and use of checklists to address this problem.
Journal Article > Commentary
The pursuit of better diagnostic performance: a human factors perspective.
Henriksen K, Brady J. BMJ Qual Saf. 2013;22(supp 2):1-5.
This commentary explores how principles from human factors can be applied to reduce diagnostic errors.
Journal Article > Study
Does inappropriate selectivity in information use relate to diagnostic errors and patient harm? The diagnosis of patients with dyspnea.
Zwaan L, Thijs A, Wagner C, Timmermans DR. Soc Sci Med. 2013;91:32-38.
Inappropriate selectivity (failure to consider all available information or potential diagnoses) was a major contributor to diagnostic errors in patients with dyspnea.
Journal Article > Commentary
Misdiagnosed food allergy resulting in severe malnutrition in an infant.
Alvares M, Kao L, Mittal V, Wuu A, Clark A, Bird JA. Pediatrics. 2013;132:e229-e332.
This commentary illustrates how misdiagnosis of food allergies can delay correct diagnosis and treatment.
Tools/Toolkit > Toolkit
Clinical Reasoning Toolkit.
SIDM Education Committee. Society to Improve Diagnosis in Medicine: 2017.
This toolkit includes resources to help clinicians and educators improve their understanding of cognitive errors and diagnostic reasoning.
Newspaper/Magazine Article
Mistakes even good doctors make.
Consumer Reports on Health. November 2013;25:6-7.
This article reveals commonly misdiagnosed conditions, why diagnostic errors occur, and tips for patients to reduce risks.
Journal Article > Study
Enhance patient safety by identifying and minimizing risk exposures affecting nurse practitioner practice.
Leigh J, Flynn J. J Healthc Risk Manag. 2013;33:27-35.
This study analyzed 200 closed malpractice claims filed against nurse practitioners and found that most of the claims involved missed or delayed diagnoses.
Journal Article > Study
Why do doctors make mistakes? A study of the role of salient distracting clinical features.
Mamede S, van Gog T, van den Berge K, van Saase JL, Schmidt HG. Acad Med. 2014;89:114-120.
Internal medicine residents made more diagnostic errors during complex clinical cases when a salient distracting feature—a case finding strongly associated with a particular disease that is actually unrelated to the problem—appeared near the beginning of the case description, but not when presented toward the end.


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Online dating sites forsale
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i am sure there are areas where this is happening, but don't be afraid if you go, okay?
just watch your purse it was 8 a night and we were told it was a cool area to stay in.
i remember gasping when i saw it because it really is remarkable.
we walked down near the beach because a few guys recommended this seafood spot called can mano.

subset: commoncrawl


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Multimarine expands in shipyard services investing on new drydock facilitiesInterview, January 2019 Tuesday, January 15th, 2019
Building on mutually beneficial relationships and taking advantage of the geographical area of Cyprus and of Limassol port that attracts a large number of vessels Multimar ine Services has proceeded to the expansion of its shipyard business the last years investing on brand new drydock facilities. Pavlos Phokas, Commercial Director of Multimar ine Services, describes the activities of Multimarine focusing on the operation of the floating dock "Ereneos" and the dedicated repairs quay in Limassol port.
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Kids are known for their high energy level, and it's your responsibility as a parent to keep them occupied with activities. Choosing activities for your children is a great way to add value to their time energy. For example, PediaSure Malaysia recommends going for a picnic with the whole family.
However, not every activity is beneficial for your kids. For example, passing a smartphone to your kids or letting them watching TV isn't always the most excellent choice. Instead, you can help your kids pick up these hobbies that are proved to assist in the development of children:
Reading is an excellent hobby for people of all ages. Developing an interest in reading will help the future of your children, and it's a significant factor in shaping their lives.
People may think reading is dull, but that's because they haven't found a book of their interest. Find a book genre that suits your children and if they're disinterested at first, give them books with lots of pictures and illustrations.
With the direct translation of "to fold paper", origami is an ancient Japanese craft. The art of origami is all about creating figures with folding techniques without cutting paper or using an adhesive.
Origami is beneficial to kids as it stimulates their cognitive development, creativity, and their patience. It may be difficult to get the hang of it first, but once your kids successfully create their first figure, it will grow on them.
There are no disadvantages for your children to be interested in music, which is it's such a great hobby for kids of all ages. Music can come in many forms, such as learning an instrument, dancing or singing.
Music is a fantastic way for kids to express themselves and an excellent hobby to develop their motor and coordination skills. It also teaches them to be disciplined and makes them appreciate art.
Some people may think the kitchen is no place for kids, but encouraging them to learn about food earlier may be more beneficial for them. The ability to prepare food is a necessary skill that even some adults don't have, so there's no reason why you shouldn't include kids when you make your meals.
First of all, kids will learn how much work and effort it takes to cook and not to waste food. Teaching them to cook will also encourage them to try different food and show them the importance of a balanced diet.
In this age where smartphones and computers are taking over our lives, it's important to plug off and get in touch with nature once in a while. Gardening is an enjoyable hobby for kids to drop their gadgets and enjoy the sun outside.
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Not only does having a hobby helps a child pass their time, but it'll also be beneficial for their growth and development. That's why it is crucial to help your children choose a useful and fun hobby.
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What is A2 Hosting? Review Hosting Providers
You have probably never heard of A2 Hosting. Neither had I initially. That is a shame. Because while they are not as'web famous' since BlueHost or HostGator, they claim to boast speeds up to 20X faster. They've also been around since 2001, formerly called Iniquinet (yes — great call about the rebranding!) . A2 Hosting has information centers across the globe from the US (Michigan), Europe (Amsterdam) and Asia (Singapore). Additionally, they make promises of'99.9% uptime' and'ace assistance'. (OK, today it's only sounding too good to be accurate.) So what's the conclusion? Could it be a blazing fast host with excellent uptime and excellent support? Or a different firm who's good with adjectives, but can't back it up with performance? Review Hosting Providers
Advantages of using A2 Hosting
A2 hosting says their speeds and customer service are excellent. Precisely how great are they really? It turns out — pretty amazing! Listed below are the reasonswhy:
Best Shared Hosting Provider We've Tested…
A2 has promised rates of up to 20x quicker than their competitors, remember? Anything close to this would be remarkable. And lucrative. Some of the top online brands load in under a second because shooting even 3 seconds to load may cause you dropping 50% your traffic. A2 Hosting page loading times came in with a mean of 351ms over a period of ten months which is 50+ percent faster than the industry average (890ms).
How can they get it?
A2 Hosting is taking additional precautions to limit the variety of individuals on'shared' hosting servers and implementing extra performance like caching which stores information in people's browsers (thereby limiting the number of occasions they must return and request information out of your website repeatedly and over again).
Click Here to sign up to your A2 Hosting Service
Quick & Powerful Customer Support
Quick load times really are nice. But none of that matters if your encounter — the aid you really do (or don't) receive when difficulties pop up — comes out lackluster. A2 Hosting follows their string of impressive performance with friendly, helpful, US-based service. They're available 24/7/365 through email, chat, phone or ticket entry.
It should not come as much of a surprise, given their A+ rating with the BBB (which is remarkable considering they've been doing so for 15+ years already). We tried reaching out with their support to supply a fair, impartial overview and were connected instantly. Their service representative was also incredibly receptive, answering our queries within a moment. Review Hosting Providers
Free'HackScan' Keeps Your Website Safe
A2 provides a couple of useful, preventative steps to keep hackers from your website with HackScan; a completely free service including
dual hosting anti virus, virus scanning, 24/7 security monitoring, and a brute force shield. Some hosts simply provide similar tools to use if you are so inclined. But unless you understand what you're doing, they're useless. A2 hosting goes over and beyond providing this service for you, providing you with'reassurance' so you just have to be concerned about running the site (and NOT constantly performing technical care ).
Free Site Migrations
A2 will help you to relocate from another hosting provider — gratis! — in case your site now uses cPanel (which many professional sites do). Moving the site yourself could be a massive hassle (if you're not the tech-savvy) or some time consuming, menial task (in case you have a huge site with many pages, graphics, etc.).
Compatible with Frequent Content Management Systems (CMS)
Installing popular content management systems like WordPress, Drupal, Joomla, OpenCart, and Magento is really a straightforward,'1-click' installation. Pretty simple and painless. In actuality, your own A2
accounts will have the A2 Optimized WordPress plugin pre-installed if you opt for the Turbo bundle.
Money Back Guarantee — 30 Days
A2 Hosting stands for their product, offering a complete refund if you don't like your experience for any reason (within 30 days). Please note that domain registrations, installation fees, SSL certificate, and other migration fees are not refundable (which is fairly common with different companies too ).
Free Content Delivery Network
In addition to complimentary virus scanning, you will also be able to use Cloudflare's Content Delivery Network (CDN). Cloudflare will track visitors to your site in order to spend the route of least resistance. This means that you'll get even quicker site rates, enhanced safety (Cloudflare CDN will prevent malicious threats), one-click installation, greater uptime, and more. The very best part? It's all totally free.
Green Web Hosting
A2 Hosting affirms the surroundings, so that you can feel good about choosing them as a hosting company. Considering that 2007, the company has partnered with Carbonfund.org to battle climate change. If caring for your environment is something that you're passionate about, it is possible to save the world just by with an A2 hosting account.
All their servers are"carbon neutral" since they purchase carbon offsets. When you purchase carbon offsets, you are funding projects that reduce the emission of greenhouse gases. Such projects are responsible for restoring forests, raising the energy efficiency of buildings or transportation, or upgrading power plants to make less pollution.
For every quantity of energy A2 cleansing uses, they're buying carbon offsets to create the world a fresher, cleaner place. Besides battling climate change, the business also enables employees to telecommute to stop unnecessary CO2 emissions.
They also recycle older servers instead of throwing out old hardware, plant trees during special promotions, and reduce trash by
using coffee mugs instead of disposable coffee cups. The company was also one of the first providers that offered Solid State Disk Drives (SSDs). These drives use much less electricity than conventional HDDs. Review Hosting Providers
Disadvantages of utilizing A2 Hosting
Our affection for A2 hosting ought to be evident by now. Excellent speed, and support go a long way in our publications. In addition, they do not nickel-and-dime you for small things such as migrations. Unfortunately, nobody is perfect. Listed below are a Couple of of A2's defects:
Uptime Has Slipped to 99.91% During the Last 10 Months
'Uptime' is vital, because the opposite — downtime — can cost you a lot of cash! That's why when someone (or any server ) informs you which they have 100% uptime, so you should not think the hype. While 100 percent could be attainable, it is VERY rare
More Costly than Average
The old adage,"You get what you pay for," rings true here. These fancy benefits come at a cost. A2 hosting will be pricier than the normal web host (coming from around the middle of the package ). Like other web hoststhey also use a common procedure of supplying the cheapest possible price if you sign up for a longer term. Traditionally their cheapest shared hosting program advertised at $3.92 intended you had to sign up for 36 weeks.
Restrictions on Cheapest Plan
If you'd like the flashy features, you will need to cough up a little more dough. For instance, their Lite program (the cheapest one) has restrictions on the number of websites (1, as opposed to infinite ) or databases (5, rather than unlimited) you receive. Nevertheless, it's well worth noting that in our experience, the cheapest plan remains much, much quicker than most other internet hosts. So you are likely still OK.
If you want turbo fast rates, you will need to sign up for the turbo plan. The
Turbo and Swift plans are similar, but the Turbo host is full-stacked with additional perks. As an instance, the Turbo host includes PHP API. APC is enabled with the Turbo program, and the host comes with an integrated caching engine. As a result of this, the speeds are lightning fast!
APC is enabled by default, and reports have 256 MB of APC memorycard. It's important to be aware that if you wish to alter how PHP is configured to the Turbo Server, then you are going to need to use the cPanel as opposed to the php.ini files. The Turbo plan compiles .htaccess documents to improve speeds, too. Turbo hosting servers do not support Ruby-based or even Python-based web software. This includes Rails and Django.
Click Here to register to your A2 Hosting Service
A2 Hosting Setup, Hosting Plans & Quick Facts
Shared Hosting: They have three main shared hosting plans:
Lite plan: This program starts at $3.92 per month. It supports 1 domain , 5 subdomains, 5 databases and 25 email account.
Swift plan: This plan begins at $4.90 a month. It supports unlimited domain names, databases and email accounts.
Turbo program: This plan begins at $9.31 each month. It supports unlimited domain names, databases and email accounts. Additionally, it comes with HTTP/2 and SPDY service for improved site speed.
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Cross Country Practice Schedule
- Sunday: 4:00pm, various locations--see calendar. Joint Practice with our Danville team-Long Run of 3-9 miles
- Tuesday: 5:00pm, various locations--see calendar. Form, strength and VO2 power. Typically 3 to 5 miles.
- Thursday: 5:00pm,Woodthrush Park in Pleasanton. General Endurance equivalent to 3-5 miles.
- Saturday: 9:00am, various locations--see calendar. Early in the season: aerobic endurance 3 to 6 miles. Late in the season: race specific speed 2-4 miles.
Between August 20-October 20 MDH will hold joint practice with CYO XC http://www.eteamz.com/stistjcyoxc/
After October 20 our schedule will be:
Sunday: 4:00pm-5:45pm Various Locations with our Pleasanton sister team. Check Team Snap Calendar.
Monday: 4:30pm-6:00pm Oak Hill Park
Wednesday: 4:30pm-6:15pm Oak Hill Park
Thursday: 4:30pm-6:00pm Oak Hill Park


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Egyptian real estate company Amer Group posted a 27.9 percent rise in net profit for the first half of 2014, it said in a bourse statement on Tuesday.
The firm, which owns hotels, restaurants and malls, among other businesses, made a net profit of 44.4 million Egyptian pounds(6.21 million US dollar) in the sixth months to end-June compared with 16.5 million pounds in the same period a year earlier. (1 US dollar = 7.1500 Egyptian pound).


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Now that summer is finally on it's way, I don't know about you but I am fully in the mood for a cocktail! Martini's, Mojitos and Margaritas are the order of the day, and we know just where to go to get the best cocktails in the Toon. So grab your mates and get ready for some of the best drinks in Newcastle upon Tyne!
Click here to check out our favourite bars and pubs in Newcastle.
Want to have a great time for less? Download the FREE StreetAway app and get great discounts at your favourite venues across the city.
Banyan is a newbie to Newcastle, but it's quickly becoming a firm favourite! Their cocktail trees are iconic, and their bar is stunning, so there's no better place to go for an afterwork drink, or a celebration with the girls. Why not head to Monument Mall this Friday and start your weekend in style? 🥂
Find it!
Easily one of the best cocktail bars in the city! Alvinos is a favourite with cocktail loving Geordies for their creative range of drinks and huge menu. In fact, they were recently voted the best cocktail bar in Newcastle! While you are guaranteed to find all the classics on their menu, remember that Alvinos are great at playing around with your favourites, or even and inventing something entirely new!
Find it!
88 Pilgrim St, Newcastle upon Tyne, NE1 6SG
Jam Jar
This Jesmond gem is a firm StreetAway fave! Jam Jar know how to do good food and good cocktails reaalllyy well. If you're on the hunt for a cool bar with a chill vibe, then Jam Jar is where you need to go. And remember - make the most of your trip with StreetAway! Check out what offers they have on the app before you go.
Find it!
88 Osbourne Road, Newcastle upon Tyne, NE2 2AP
The Botanist
Focusing of floral flavours and impressive presentation, The Botanist has some of he most magical cocktails in Newcastle. Add a bit of drama to your evening with their sharing cocktail served in a watering can! It's also such a stunning setting, with Monument dome covered in fairy lights, and the garden chic decor, you'll get a great pic for your Instagram feed!
Find it!
Monument Mall, Newcastle upon Tyne, NE1 7AL
The Holy Hobo
This cocktail bar is a real treat! With drinks inspired by old school tuck shops, The Holy Hobo one of StreetAway's favourites - once glance at the menu and it's easy to see why! It's the perfect blend of nostalgic flavours and great tasting booze. So why not take a trip to Jesmond to experience this incredible cocktail bar this weekend?! We'll cheers to that!


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When is my retainer due?
A retainer is due as soon as a quote is sent in order to solidify the booking and save the date!
When is my full balance due?
The full balance for a wedding or other event is due two weeks prior to the event to ensure that payment is complete before a photographer comes out to the event!
Do you do destination weddings?
Absolutely! We definitely can travel to your destination wedding! Lets get in contact and begin planning!
How long is the entire booking process?
The entire booking process can be completed in a matter of days following the completion of scheduled consolation, as soon as a retainer is put down, the event is officially booked!
Do you deliver every image you shoot?
No, we only deliver the best images from the bunch! I shoot as many images as i can to make sure you have a good amount of images!
Does your business provide videography services?
No, we currently do not provide videography services!
Do you do destination weddings?
Yes! We do destination weddings with my team, contact us to book now!
Have you shot at my venue before?
If you would like to know if we have shot an event or wedding at your venue, get in contact and we would be glad to let you know!
Which photographer will be shooting my wedding?
Mayowa Obatuase himself will be the photographer on the day of your wedding, with a team of assistants, and secondary-shooters contracted with the business!
Do you provide partial day coverage?
Generally, no - but in special circumstances it may be possible!
Do you shoot in JPEG, Small Raw, or Large Raw?
We shoot in Large Raw, if requested, we can shoot in whatever format you would like!
Do you shoot Quinceaneras, Debutants, Bah Mitzvahs, or Corporate Events?
Yes! Shoot us an email email@example.com and we can begin discussing your future event!
Does your studio do Headshots, Individual Portraits, Family Portraits?
Yes! We specialize in wedding, and portrait photography, therefore we do all sorts of sessions!


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Hi, I am glad i can be finally part of this. My first shot, be gentle on me pls :)
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MichBio kick's off the legislative events at the Capitol with a Reception for the Michigan delegation.
This reception is MichBio's way of kicking-off the BIO Legislative Day Fly-In (April 3-4) with the Michigan Delegation in Washington D.C. The event provides an opportunity for MichBio staff and other Bioscience advocates to meet and build relationships with the Michigan legislators surrounding issues important to the bio-industry.
by delivering business-critical resources & bottom line savings
by connecting Michigan's bio-industry one member at a time
by influencing business growth through advocacy
by creating opportunities that develop people & build organizations
3520 Green Ct., Suite 175
Ann Arbor, MI 48105-1175
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EMAIL: firstname.lastname@example.com


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"I was always asked 'When are you going to do another one?' Well, you've been very patient with me. I felt like it was my responsibility to really deliver for you."
To huge cheers from the crowd gathered in Comic-Con's Hall H, Tom Cruise made a surprise appearance to introduce the trailer to TOP GUN: MAVERICK, calling it "a love letter to aviation."
The trailer revealed today opens on a desert plain with a jet rising to course over it. Ed Harris' voice-over is heard "Thirty-plus years of service…you can get promoted or retire, but you refuse to die. You should be a two-star admiral, yet here you are a captain." Then images of Cruise in the iconic leather jacket, racing on the motorcycle, singing in the bar with his buds, Jon Hamm stepping on the airfield as a commander, and shots of Cruise flying in a snowy caravan. "Maverick you should be headed to extinction," says Harris. Cruise answers, "Maybe so, sir, but not today."


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- This event has passed.
Comments due: FDIC, Federal Reserve (proposed rule; resolution plans required)
June 21
The Board and the Corporation (together, the agencies) are inviting comment on a proposal to amend and restate the jointly issued regulation (the Rule) implementing the resolution planning requirements of section 165(d) of the Dodd-Frank Wall Street Reform and Consumer Protection Act (12 U.S.C. 5365(d)) (the Dodd-Frank Act). The proposal is intended to reflect improvements identified since the Rule was finalized in November 2011 and to address amendments to the Dodd-Frank Act made by the Economic Growth, Regulatory Relief, and Consumer Protection Act (EGRRCPA).


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Arrivederci Milano!
I mentioned in the last post about my obsession with detail whilst in Milan. This is some of the evidence of that. Milan was very good for detail photographs. These are just a few little tidbits from my last day in Milan. Next stop: Padova!
Giardini di Milano
Castello di Milano
Milano was one city we visited where I didn't do a huge amount of research prior to getting there so stumbling upon a castle whilst there was a nice surprise. Sforza Castle is very different from other castles I saw in Europe. It felt much less extravagant, strangely enough. The place was practically crawling with stray cats, though I certainly didn't mind that one bit (crazy cat lady in the making right here). It was very different, but I liked it.
Mercati di Milano
There was so much delicious food in Milano. The market stalls not only sold a wide range of interesting trinkets, but also different types of food as well. I tried the cranberries in chocolate and they were so wonderfully rich and decadent. I also ate a HUGE amount of gelato in Italy. That stuff is amazing. Also, pasta. Any type of pasta, any time of day, I am perfectly happy to consume it. In fact, just give me all the Italian food, I love it all.
Rooftop Modelling
Hi! I'm Louise. I am a writer, photographer, traveler, book fanatic and blogger. I love to post about my adventures and the little things I do that make life fun.
April 2019


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If your iPhone is rebooting or your Messages app is consistently crashing, you might be the victim of an iOS exploit or just a buggy software program update. Observe the post of the sufferer on a map and see the place he is now. Take these pixels, twist them in a knot, and see for your self! At the highest proper of every of your photographs in your board you see a pencil which is 'edit'. You'll be able to very simply retailer your favourite songs and photos whereas also having fun with the quite a few MP3 and polyphonic ringtones included. You can even download some memes or make your personal message utilizing one of many captions out there to ship as a text message. Getting the one which is right on your group alongside along with your customers Andrew Luck Jersey may be so simple as checking out their web sites. An additional instance will be discovered in the Hemisphere FOIA document.
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Fall Zoovie Nights event activities are included with your Zoo admission and are FREE for Zoo Members. On Oct. 27, watch Hocus Pocus at the Zoo.
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