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psnet.ahrq.gov/web-mm/thin-air
March 01, 2006 - It is probably even more common for oxygen tubing to become disconnected from a correct flowmeter during … Interlocks enforce correct sequencing or isolate events in time; often they are used to prevent one action … The Pin Index System played no role here, since it forces the correct regulator on the matching tank … gas: - Eliminate air flowmeters; - Permanently fix Christmas tree adapters to the correct … The air and oxygen flowmeters with the correct Christmas tree adapters.
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psnet.ahrq.gov/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
January 01, 2020 - • Differentiate the human and technologic roles involved in delivering the correct
blood to the … correct patient
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psnet.ahrq.gov/node/49781/psn-pdf
January 01, 2017 - The ED physician ordered the correct
loading dose of intravenous (IV) phenytoin, to be administered … computerized prescribing systems should have checks in place that flag
potential dosing errors and provide correct … systems should have dosing checks in place that not only flag potential
dosing errors, but also provide correct
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psnet.ahrq.gov/issue/utility-clinical-examination-diagnosis-emergency-department-patients-admitted-department
April 06, 2022 - This research letter examines the value of the physical examination in forming a correct diagnosis
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psnet.ahrq.gov/node/38033/psn-pdf
September 24, 2010 - implementing-online-medication-reconciliation-large-academic-medical-center
Medication reconciliation—the process of cross-checking patients' medication lists to correct
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psnet.ahrq.gov/node/46550/psn-pdf
November 15, 2017 - professional interpreter perceptions regarding their role in patient safety
and found that it extends beyond correct
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psnet.ahrq.gov/node/47598/psn-pdf
November 28, 2018 - hospital-admissions-associated-medication-non-adherence-systematic-review-prospective
https://psnet.ahrq.gov/issue/beyond-medication-reconciliation-correct-medication-list
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psnet.ahrq.gov/node/36975/psn-pdf
March 24, 2011 - Safety of telephone triage in general practitioner
cooperatives: do triage nurses correctly estimate
urgency?
March 24, 2011
Giesen P, Ferwerda R, Tijssen R, et al. Safety of telephone triage in general practitioner cooperatives: do
triage nurses correctly estimate urgency? Qual Saf Health Care. 2007;16(3):181-4.
…
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psnet.ahrq.gov/node/42515/psn-pdf
October 24, 2013 - Using four-phased unit-based patient safety walkrounds
to uncover correctable system flaws.
October 24, 2013
Taylor AM, Chuo J, Figueroa-Altmann A, et al. Using four-phased unit-based patient safety walkrounds to
uncover correctable system flaws. Jt Comm J Qual Patient Saf. 2013;39(9):396-403.
https://psnet.ahrq.g…
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psnet.ahrq.gov/issue/patient-safety-dermatologic-surgery-part-1-patient-safety-procedural-dermatology-part-2
October 04, 2023 - issues and error reduction tactics in dermatologic surgical practice , highlighting the importance of correct
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psnet.ahrq.gov/issue/how-insight-contributes-diagnostic-excellence
June 08, 2022 - These authors discuss how insight – or the spontaneous emergence of the correct answer at a later point
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psnet.ahrq.gov/primer/computerized-provider-order-entry
March 15, 2025 - drug–drug interactions and allergies, then release the appropriate quantity of the medication in the correct … Administration : the medication must be received by the correct person and supplied to the correct patient
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psnet.ahrq.gov/issue/registration-associated-patient-misidentification-academic-medical-center-causes-and
September 02, 2020 - Study
Registration-associated patient misidentification in an academic medical center: causes and corrections.
Citation Text:
Bittle MJ, Charache P, Wassilchalk DM. Registration-associated patient misidentification in an academic medical center: causes and corrections. Jt Comm J Qual Pat…
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psnet.ahrq.gov/issue/hidden-plain-sight-reconsidering-use-race-correction-clinical-algorithms
September 23, 2020 - Commentary
Classic
Hidden in plain sight — reconsidering the use of race correction in clinical algorithms.
Citation Text:
Vyas DA, Eisenstein LG, Jones DS. Hidden in plain sight — reconsidering the use of race correction in clinical algorithms. N Engl J Med. 20…
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psnet.ahrq.gov/node/45953/psn-pdf
July 22, 2020 - Root Cause Analysis in Health Care: A Joint Commission
Guide to Analysis and Corrective Action of Sentinel and
Adverse Events.
July 22, 2020
Oakbrook Terrace, IL: Joint Commission Resources; 2020. ISBN: 9781635851618.
https://psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and-…
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psnet.ahrq.gov/node/43393/psn-pdf
July 30, 2014 - Effectiveness of the surgical safety checklist in correcting
errors: a literature review applying Reason's Swiss
cheese model.
July 30, 2014
Collins SJ, Newhouse R, Porter J, et al. Effectiveness of the surgical safety checklist in correcting errors: a
literature review applying Reason's Swiss cheese model. AORN J…
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psnet.ahrq.gov/node/37688/psn-pdf
April 16, 2008 - Role of registered nurses in error prevention, discovery
and correction.
April 16, 2008
Rogers AE, Dean GE, Hwang W-T, et al. Role of registered nurses in error prevention, discovery and
correction. Qual Saf Health Care. 2008;17(2):117-21. doi:10.1136/qshc.2007.022699.
https://psnet.ahrq.gov/issue/role-registered-…
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psnet.ahrq.gov/issue/root-cause-analysis-core-problem-solving-and-corrective-action-second-edition
June 09, 2011 - Book/Report
Classic
Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition.
Citation Text:
Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition. Oakes D. Milwaukee, WI: ASQ Quality Press; 2019. IS…
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psnet.ahrq.gov/node/41796/psn-pdf
January 18, 2013 - commonly use to prevent RSIs, but in this
study 45 of 59 RSI cases had counts that were erroneously "correct
-
psnet.ahrq.gov/node/36303/psn-pdf
October 25, 2010 - Bar code technology has been widely recommended to reduce adverse drug events (ADEs) by ensuring
the correct