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psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - One of the questions was: Have you ever
assumed a medication order was correct despite a concern you
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - prescribing practices, build alerts for unsafe prescribing, and provide conversion support to calculate correct
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psnet.ahrq.gov/web-mm/monitoring-fetal-health
September 08, 2010 - Further, correct detections decreased as time on task progressed, consistent with numerous other vigilance
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - The trauma surgery team and orthopedic consultant were correct to adopt a deliberate and conservative
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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - It is important to remember that patients do not need to make the “correct choice”;
however, they do
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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - • It is important to remember that patients do not need to make the
“correct choice”; however, they
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psnet.ahrq.gov/node/72614/psn-pdf
March 01, 2021 - particularly international), additional
results from expanded use, additional publications, and ensuring the correct
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psnet.ahrq.gov/perspective/equity-patient-safety
September 24, 2024 - Even if AI developers working in healthcare correct algorithms that may perpetuate structural racism,
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psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - 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/866261/psn-pdf
July 10, 2024 - considered early
Well leg compartment syndrome is uncommon and there is often a delay in making the correct
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psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - After the innovation team developed colonoscopy registries, a chart review was conducted to confirm the correct
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psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
January 29, 2021 - Look for and correct electrolyte disturbances that may exacerbate muscle weakness.
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - the innovation team developed colonoscopy registries, a
chart review was conducted to confirm the correct
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - Correct application of electrodes (e.g., who will apply electrodes initially; who will note if the electrodes
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psnet.ahrq.gov/node/846171/psn-pdf
July 26, 2022 - Health care providers must establish that the NGT is in the correct location before using it and
continue
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psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
July 02, 2019 - When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication
Citation Text:
Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - Hyperglycemia and Switching to Subcutaneous Insulin
Citation Text:
Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/too-tight-control
March 20, 2013 - SPOTLIGHT CASE
Too Tight Control
Citation Text:
Rubin HR, Fajtova VT. Too Tight Control. 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/865778/psn-pdf
May 29, 2024 - Navigating Complications: The Unintended Journey of a
Guidewire During Dialysis Catheter Placement
May 29, 2024
Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis
Catheter Placement. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-complications-unint…