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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - oncology fellow inadvertently chose the wrong paper order set—he saw that the order set included the correct
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psnet.ahrq.gov/web-mm/time-death
January 03, 2017 - Improving cardiopulmonary resuscitation skills retention: effect of two checklists designed to prompt correct
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psnet.ahrq.gov/node/857258/psn-pdf
November 30, 2023 - Look for and correct electrolyte disturbances that may exacerbate muscle weakness.
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psnet.ahrq.gov/node/49750/psn-pdf
January 01, 2016 - physician communicates to a nurse
assigned to locate an appropriate bed for the patient (i.e., on the correct
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psnet.ahrq.gov/node/49717/psn-pdf
September 01, 2014 - prescribing practices, build alerts for unsafe prescribing, and provide conversion support to
calculate correct
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psnet.ahrq.gov/node/49792/psn-pdf
May 01, 2017 - One operational
definition of diagnostic error is missed opportunities to make a correct or timely diagnosis
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psnet.ahrq.gov/node/33793/psn-pdf
November 01, 2015 - RW: Another tension is the degree to which a patient safety intervention can be "proven correct"—a single
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psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
September 25, 2019 - involving patients, their families, clinicians, and other members of the health care team that leads to correct
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psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
September 01, 2004 - System administrators can use the frequency of such pairs and triples to identify and correct the most
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psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
September 18, 2024 - One operational definition of diagnostic error is missed opportunities to make a correct or timely diagnosis
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psnet.ahrq.gov/node/865466/psn-pdf
March 27, 2024 - Even if AI developers working in healthcare correct algorithms that may perpetuate structural racism,
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - Given the failure to wean from mechanical ventilation, the decision to place a tracheostomy tube was correct
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psnet.ahrq.gov/web-mm/round-trip-service
April 26, 2023 - Round-Trip Service
Citation Text:
McGrath MH. Round-Trip Service. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/865374/psn-pdf
March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and
Challenges
March 27, 2024
Tighe P, Mossburg S, Gale B. Artificial Intelligence and Patient Safety: Promise and Challenges. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
Introducti…
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psnet.ahrq.gov/web-mm/caution-interrupted
October 01, 2016 - Caution, Interrupted
Citation Text:
Wears RL. Caution, Interrupted. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/49609/psn-pdf
October 01, 2010 - Dangerous Dialysis
October 1, 2010
Holley JL. Dangerous Dialysis . PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/dangerous-dialysis
Case Objectives
List common errors that occur in dialysis units.
Describe steps that can be taken by dialysis units to prevent these common errors.
Describe the role of the …
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psnet.ahrq.gov/web-mm/over-counter-oversight
March 21, 2009 - Over-the-Counter Oversight
Citation Text:
Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something
May 01, 2019 - Liver Failure After Chemotherapy: Did We Forget Something?
Citation Text:
Lubel J. Liver Failure After Chemotherapy: Did We Forget Something?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph
December 21, 2022 - In Conversation with…Troyen A. Brennan, MD, JD, MPH
December 1, 2005
Citation Text:
In Conversation with…Troyen A. Brennan, MD, JD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
…
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psnet.ahrq.gov/web-mm/fire-hole-or-fire
August 03, 2017 - Fire in the Hole!—An OR Fire
Citation Text:
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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