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psnet.ahrq.gov/node/854263/psn-pdf
November 03, 2023 - diagnostic-safety-and-quality-webinar-series-overview-and-implications-
hospitals
Diagnostic errors in hospitals are the focus on continued
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psnet.ahrq.gov/node/48106/psn-pdf
July 24, 2019 - https://psnet.ahrq.gov/issue/teamwork-toolkit
Improving teamwork and communication is a continued focus
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psnet.ahrq.gov/node/47696/psn-pdf
February 22, 2019 - /issue/operating-room-fires
https://psnet.ahrq.gov/issue/surgical-fires-decreasing-incidence-relies-continued-prevention-efforts
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psnet.ahrq.gov/node/60586/psn-pdf
June 10, 2020 - This
webinar featured tactics used and discussed initiative results to inform continued improvement.
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psnet.ahrq.gov/node/867391/psn-pdf
December 18, 2024 - Continued research to mitigate cognitive biases is required.
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psnet.ahrq.gov/node/45958/psn-pdf
January 01, 2021 - The authors advocate
for continued uptake of this health information technology strategy to enhance
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psnet.ahrq.gov/node/853977/psn-pdf
September 27, 2023 - discusses a rare criminal
event in the British National Health System (NHS) and the factors that allowed continued
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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - This approach was not adequate and led to continued postoperative bleeding and eventual death from untreated … may have been an appropriate plan to start, but the lack of further intervention when the bleeding continued … Approaches to Improving Patient Safety (1)
19
Once the initial management failed and the patient continued … 4)
22
The vignette provides little discussion about what occurred overnight as the patient’s status continued … This problem was compounded when they continued to ignore signs of ongoing postoperative bleeding.
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psnet.ahrq.gov/node/74046/psn-pdf
January 01, 2022 - approaches
contribute to misdiagnosis and suggests that successes be mined to minimize the proliferation of continued
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psnet.ahrq.gov/node/47645/psn-pdf
April 17, 2019 - when-nurse-prosecuted-fatal-medical-mistake-does-it-make-medicine-safer
Punitive responses to medical errors persist despite continued
-
psnet.ahrq.gov/node/837211/psn-pdf
May 25, 2022 - This
commentary discusses strategies to instigate continued energy toward reducing medical error: prioritization
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psnet.ahrq.gov/node/50808/psn-pdf
January 15, 2020 - health-services-research-priorities-improving-diagnostic-safety-and-quality-
special-emphasis
This announcement highlights AHRQ continued
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psnet.ahrq.gov/issue/medical-errors-are-third-leading-cause-death-and-other-statistics-you-should-question
February 24, 2025 - rates of medical errors continue to draw attention to gaps in care that demonstrate the need for continued
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.113_slideshow.ppt
January 01, 2006 - Indication Prevention Strategy
General Surgery UFH 5,000 units q 8h, 1st dose 2h preoperatively, continued … 2.0-3.0
Warfarin daily, 1st dose 5 mg preoperative evening, adjusted to target INR of 2.0-3.0 and continued … Prevention Strategy
Total Knee Replacement Enoxaparin 30 mg BID, beginning 12-24h postoperatively, continued … Indication Prevention Strategy
Neurosurgery Enoxaparin 40 mg daily, 1st dose ≤ 24h postoperatively, continued … for Brain Tumor Enoxaparin 40 mg daily or UFH 5,000 units BID, 1st dose on 1st postoperative morning, continued
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psnet.ahrq.gov/node/866271/psn-pdf
July 10, 2024 - There was high variability in error types across approaches
and electronic health record systems; continued
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psnet.ahrq.gov/node/74750/psn-pdf
February 09, 2022 - increased-adherence-perioperative-safety-guidelines-associated-improved-
patient-safety
A necessary part of successful implementation of new guidelines is ensuring continued
-
psnet.ahrq.gov/node/73463/psn-pdf
July 07, 2021 - issue/structural-racism-and-covid-19-experience-united-states
The COVID-19 pandemic highlighted the continued
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psnet.ahrq.gov/node/852284/psn-pdf
August 09, 2023 - Published rates of medical errors continue to draw attention to gaps in care that demonstrate the need for
continued
-
psnet.ahrq.gov/node/866205/psn-pdf
July 10, 2024 - This approach was not adequate and led to continued
postoperative bleeding and eventual death from untreated … may have been an appropriate plan to start, but the lack of further intervention when the
bleeding continued … /psnet.ahrq.gov//#4
https://psnet.ahrq.gov//#5
Once the initial management failed and the patient continued … The case provides little discussion about what occurred overnight as the patient’s status continued to … This problem was compounded when they continued to ignore signs of ongoing postoperative
bleeding.
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psnet.ahrq.gov/node/866119/psn-pdf
June 12, 2024 - The policy
concludes with a call for continued research to support the effective development and safe