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psnet.ahrq.gov/web-mm/liposuction-gone-awry
July 01, 2003 - Related Resources From the Same Author(s)
WebM&M Cases
Code
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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - A "Code STEMI" (ST-elevation myocardial infarction) was called, but the clinicians chose to delay taking
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psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - November 1, 2006
WebM&M Cases
Deciphering the Code
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psnet.ahrq.gov/web-mm/discharge-against-medical-advice
July 01, 2017 - March 1, 2006
WebM&M Cases
Deciphering the Code
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psnet.ahrq.gov/node/49747/psn-pdf
December 01, 2015 - A code blue was called but the patient had been dead for some time.
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psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
February 10, 2010 - June 28, 2017
WebM&M Cases
Code Status vs.
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psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
October 30, 2024 - consisted of establishing an AAM long-term oversight committee similar to existing Critical Care and Code
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psnet.ahrq.gov/node/50928/psn-pdf
February 21, 2020 - guideline
https://psnet.ahrq.gov/issue/development-and-implementation-subcutaneous-insulin-pen-label-bar-code-scanning-protocol
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psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
March 01, 2006 - : Clarifying Code Status
December 18, 2019
WebM&M Cases
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psnet.ahrq.gov/node/49400/psn-pdf
May 01, 2003 - A full code ensued and after a brief time, the patient was
stabilized with a blood pressure of 95/55
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - However, only 25% of the last 16 reported patients had an ICD-9-CM secondary diagnosis code of a pressure … points out, an unintended consequence is that tying penalties in payment to the presence of a diagnosis code … August 8, 2012
Implementation of bar-code medication administration to reduce patient
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - A code blue was called for opioid and benzodiazepine overdose.
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psnet.ahrq.gov/node/866217/psn-pdf
July 10, 2024 - In Conversation With...Amy Helwig about Health Plan
Patient Safety Initiatives
July 10, 2024
Helwig A, Sousane Z, Mossburg S. In Conversation With..Amy Helwig about Health Plan Patient Safety
Initiatives. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patie…
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psnet.ahrq.gov/node/33850/psn-pdf
January 01, 2018 - EHR Copy and Paste and Patient Safety
January 1, 2018
Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
Perspective
Although the ability to copy and paste text is a central benefit of computing in general, and electronic…
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psnet.ahrq.gov/node/60169/psn-pdf
March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration
errors in the operating room.
March 25, 2020
Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…
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psnet.ahrq.gov/node/49510/psn-pdf
May 01, 2006 - Cups of Error
May 1, 2006
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/cups-error
The Case
An 87-year-old man was 5 days postoperative from a decompressive laminectomy. Although he suffered
from dementia, he remained alert and oriented with only mild short-term memory…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
February 01, 2012 - Spotlight Case July 2008
Spotlight Case
E-prescribing: E for Error?
1
2
Source and Credits
This presentation is based on the February 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…
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psnet.ahrq.gov/node/40243/psn-pdf
June 10, 2018 - Preventing medication errors during codes.
June 10, 2018
ISMP Medication Safety Alert! Acute care edition. February 9, 2011;16:1-3.
https://psnet.ahrq.gov/issue/preventing-medication-errors-during-codes
This piece discusses medication errors during emergency resuscitations and outlines risk-reduction
strategies.
…
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psnet.ahrq.gov/node/35603/psn-pdf
February 06, 2019 - Use of color-coded patient wristbands creates
unnecessary risk.
February 6, 2019
PA PSRS Patient Saf Advis 2005 Dec 2;(Suppl. 2):1-4.
https://psnet.ahrq.gov/issue/use-color-coded-patient-wristbands-creates-unnecessary-risk
This supplemental advisory recommends that a limited, standard set of colors and correspondi…
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psnet.ahrq.gov/node/36729/psn-pdf
June 17, 2014 - Coding for Success: Simple Technology for Safer Patient
Care.
June 17, 2014
Healthcare Quality Directorate, Department of Health. London, UK; Crown Copyright: 2007.
https://psnet.ahrq.gov/issue/coding-success-simple-technology-safer-patient-care
This report discusses the impact that automated technologies, such as…