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psnet.ahrq.gov/node/49770/psn-pdf
September 01, 2016 - Wrong-Time Error With High-Alert Medication
September 1, 2016
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
The Case
A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…
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psnet.ahrq.gov/node/49803/psn-pdf
January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3
August 1, 2017
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
The Case
A 2-month-old boy was brought in for a routine 2-month well-child visit. The exam was completed and the
app…
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psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
April 01, 2009 - In ex post evaluation, it is particularly important to detect and assess unforeseen consequences. … Second, they need to improve their use of monitoring and evaluation of both intended and unintended consequences
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psnet.ahrq.gov/node/72586/psn-pdf
December 23, 2020 - For example, a patient may
demonstrate appreciation by verbalizing the consequences to themselves by … Cognitive underspecification: Its variety and consequences. ?In B.
J. Baars (Ed.), ?
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psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
May 11, 2014 - WebM&M Cases
To Dilute or Not Dilute: Drug Errors and Consequences
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psnet.ahrq.gov/web-mm/deciphering-code
November 16, 2022 - Some unintended consequences of information technology in health care: the nature of patient care information
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psnet.ahrq.gov/web-mm/or
August 22, 2013 - The patient awakened without event and suffered no adverse consequences from the error.
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psnet.ahrq.gov/node/50389/psn-pdf
September 25, 2019 - esoteric when
considering a real case such as the one presented here, they have very real clinical consequences
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psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
July 20, 2016 - The consequences in either case—local tissue injury with the use of peripheral vasopressors, or prolonged
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psnet.ahrq.gov/web-mm/painful-dilemma
September 01, 2013 - drug-taking behaviors—such as loss of control over use, continued use despite knowledge of harmful consequences
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psnet.ahrq.gov/node/49512/psn-pdf
May 01, 2006 - anesthesia was reversed, and the patient was returned to her room and fortunately did not have
any consequences
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psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
December 18, 2019 - (or surrogate) ideally should be able to understand the choices being considered, assess the likely consequences
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psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
June 01, 2005 - Rural Hospital
June 1, 2018
WebM&M Cases
Consequences
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psnet.ahrq.gov/node/49863/psn-pdf
May 01, 2019 - transfusion of multiple units of blood, and
fortunately the injury was repaired before more serious consequences
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psnet.ahrq.gov/node/33722/psn-pdf
December 01, 2011 - They understand the consequences of an injurious patient fall, that it can be life
altering and life
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psnet.ahrq.gov/periodic-issue/periodic-issue-302
July 28, 2021 - WebM&M Cases
Spotlight Case
The Consequences of Miscommunication Regarding a Possible Artifact
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psnet.ahrq.gov/periodic-issue/periodic-issue-311
September 29, 2021 - Transfusion errors can have serious consequences.
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psnet.ahrq.gov/periodic-issue/periodic-issue-310
September 29, 2021 - In a novel finding, this study identified potential negative consequences of psychological safety, including
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psnet.ahrq.gov/periodic-issue/periodic-issue-346
May 16, 2022 - The commentary highlights the consequences of patient transport errors and strategies to enhance the
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psnet.ahrq.gov/periodic-issue/periodic-issue-347
May 16, 2022 - The commentary highlights the consequences of patient transport errors and strategies to enhance the