-
psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - If the patient and family had known the correct diagnosis of her foot pain and reported that history … consistent; (ii) marking the operative site; and (iii) a “time out” to conduct a final verification of the correct
-
psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake
September 29, 2021 - Newspaper/Magazine Article
RaDonda Vaught says some system practices contributed to fatal mistake.
Citation Text:
RaDonda Vaught says some system practices contributed to fatal mistake. Clark C. MedPage Today. March 14, 2024.
Copy Citation
Save
Save to…
-
psnet.ahrq.gov/web-mm/watch-warfarin
December 01, 2013 - at risk for thromboembolic events until the medication is restarted.( 8 ) The medical team was also correct … ceftriaxone and doxycycline) that may increase INR levels.( 9 ) And finally, the outpatient physician was correct
-
psnet.ahrq.gov/web-mm/worst-headache
July 01, 2016 - mildly affected patients, who may lack classic symptoms and signs, have the most to gain by prompt correct … stage (which would have a sensitivity of about 80%) should not have reassured the clinician and the correct
-
psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third-edition
May 18, 2016 - Book/Report
Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction, Third Edition.
Citation Text:
Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction, Third Edition. Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404066.
…
-
psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - physicians missed the diagnosis of diabetic ketoacidosis (DKA) in a patient with type 1 diabetes; the correct … stepwise approach that included calculating the anion gap and excess anion gap would have prevented the correct
-
psnet.ahrq.gov/node/33578/psn-pdf
September 15, 2024 - The widening use of
checklists as a means of ensuring that safety steps are performed in the correct
-
psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - The nurse documented the surgical counts as correct and “vag pack with Premarin ® cream by doctor, gauze … the nursing intraoperative record, the operating room (OR) nurse documented the surgical counts as correct … evidence from a primary source provider that packing is in place, then the action agent has to answer the correct
-
psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation
March 27, 2024 - Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation
Citation Text:
Kulig CE, Ebong IA. Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
…
-
psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - professionals and administrators have often showed greater engagement in patient safety than physicians, but correct … certification examination showed that, for cases involving diagnosis, changing an answer from incorrect to correct … occurred nearly twice as often as changing an answer from correct to incorrect.
-
psnet.ahrq.gov/web-mm/harm-alarm-fatigue
February 14, 2018 - In this case, the providers were correct in concluding that the telemetry monitor device was misreading … these alarms by checking on the patient (multiple times) and contacting the responsible physician, the correct
-
psnet.ahrq.gov/primer/diagnostic-errors
June 15, 2024 - at all, meaning that organizations could score well on quality measures even if patients receive the correct
-
psnet.ahrq.gov/issue/improving-cancer-patient-care-combined-medication-error-reviews-and-morbidity-and-mortality
February 01, 2012 - Study
Improving cancer patient care with combined medication error reviews and morbidity and mortality conferences.
Citation Text:
Ranchon F, You B, Salles G, et al. Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences. Chemotherapy…
-
psnet.ahrq.gov/issue/essential-guide-patient-safety-officers-second-edition
February 15, 2017 - Book/Report
The Essential Guide for Patient Safety Officers, Second Edition.
Citation Text:
The Essential Guide for Patient Safety Officers, Second Edition. Leonard M, Frankel A, Federico F, et al, eds. Oakbrook Terrace, IL: Joint Commission Resources, Institute for Healthcare Improv…
-
psnet.ahrq.gov/issue/predictors-likelihood-speaking-about-safety-concerns-labour-and-delivery
October 19, 2022 - Study
Predictors of likelihood of speaking up about safety concerns in labour and delivery.
Citation Text:
Lyndon A, Sexton B, Simpson KR, et al. Correction. BMJ Qual Saf. 2011;22(2):791-799. doi:10.1136/bmjqs.2010.050211.
Copy Citation
Format:
DOI Google Scholar BibTeX E…
-
psnet.ahrq.gov/perspective/remote-patient-monitoring
March 15, 2023 - To support the correct use of devices according to guidelines and avoid false values, organizations should … There is not a single correct answer for this. … Ideally, patients would notify us in those cases and we could correct that data. … Sarah Mossburg: As payment models evolve, is it correct to think there will be more opportunities for
-
psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
March 15, 2023 - There is not a single correct answer for this. … Ideally, patients would notify us in those cases and we could correct that data. … Sarah Mossburg: As payment models evolve, is it correct to think there will be more opportunities for … To support the correct use of devices according to guidelines and avoid false values, organizations should
-
psnet.ahrq.gov/web-mm/nothing-called-small-surgery
February 01, 2023 - reliable and safe pressure, and to follow the manufactures’ guidelines for use, especially choosing the correct … procedure cannot be concluded until all foreign objects are accounted for and the surgical count is correct
-
psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - medications a patient is taking—including name, dosage, frequency, and route—and using this list to provide correct … or reconfirm the patient's PAML with the patient, allowing them to miss additional opportunities to correct
-
psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - The answer must be correct - there is no
partial credit for being close.