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psnet.ahrq.gov/web-mm/cups-error
January 12, 2011 - Cups of Error
Citation Text:
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/patient-mix
December 01, 2007 - Patient Mix-Up
Citation Text:
Shojania KG. Patient Mix-Up. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
June 01, 2014 - Mixup Beyond the Medication Label
Citation Text:
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates
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February 9, 2021
…
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psnet.ahrq.gov/node/49622/psn-pdf
March 01, 2011 - Dropping the Ball Despite an Integrated EMR
March 1, 2011
Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
The Case
A patient followed at a community-based clinic that is part of a large health care system with an
in…
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psnet.ahrq.gov/primer/electronic-health-records
March 15, 2025 - Electronic Health Records
Citation Text:
Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - For patient X in room Y, the patient's code status is .
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psnet.ahrq.gov/web-mm/lost-transition
November 17, 2010 - May 1, 2006
WebM&M Cases
Deciphering the Code
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - Medication dispensing errors and potential adverse drug events before and after implementing bar code
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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - Medication dispensing errors and potential adverse drug events before and after implementing bar code
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psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - Computer devices with PHI are required by state laws to be encrypted (data is converted into code that
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psnet.ahrq.gov/node/33580/psn-pdf
April 01, 2022 - vocational (practical) nurses (LVN), and other
staff to provide nursing care to patients as needed (42 Code
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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - Luckily, the arrest occurred in front of a staff who called a code blue.
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psnet.ahrq.gov/node/49618/psn-pdf
February 01, 2011 - The Culture Code: An Ingenious Way to Understand Why People Around the World Live
and Buy as They Do
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psnet.ahrq.gov/node/863308/psn-pdf
February 28, 2024 - A call for additional
help via an overhead paging system (e.g., “code blue”) is critical to have extra
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psnet.ahrq.gov/node/72689/psn-pdf
January 29, 2021 - appropriate was 90% or greater for each
of the following: 1) at the request of a nurse, 2) activation of a code
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psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - pumps" (infusion pump that alerts operators when it is infusing outside of pre-configured limits), bar-code
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - vocational (practical) nurses (LVN), and other staff to provide nursing care to patients as needed (42 Code
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psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - participating in care until 02:45
on post-operative day 1
• At 04:05, patient was found unresponsive and Code
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psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
January 01, 2018 - told it's not that hard to highlight text that has been copied and pasted, either italicize or color code