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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - In the first case, laboratory monitoring was correctly ordered at discharge but never completed at the
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psnet.ahrq.gov/issue/use-complete-medication-history-identify-and-correct-transitions-care-medication-errors
October 28, 2020 - Study
Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission.
Citation Text:
Vargas V, Blakeslee WW, Banas CA, et al. Use of complete medication history to identify and correct transitions-of-care medication erro…
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psnet.ahrq.gov/node/33610/psn-pdf
April 01, 2005 - It soon became clear that cases of medical errors, if mined correctly, could play an essential role in
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psnet.ahrq.gov/node/836935/psn-pdf
April 13, 2019 - Root Cause Analysis: The Core of Problem Solving and
Corrective Action, Second Edition.
April 13, 2019
Oakes D. Milwaukee, WI: ASQ Quality Press; 2019. ISBN: 9780873899826.
https://psnet.ahrq.gov/issue/root-cause-analysis-core-problem-solving-and-corrective-action-second-edition
Root cause analysis is a widely use…
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psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
August 10, 2019 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable
Citation Text:
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy C…
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psnet.ahrq.gov/node/35692/psn-pdf
December 24, 2014 - Ensuring Correct Surgery.
December 24, 2014
National Center for Patient Safety; NCPS
https://psnet.ahrq.gov/issue/ensuring-correct-surgery
This pamphlet informs consumers on steps both patients and clinicians should take prior to surgery to
ensure safety.
https://psnet.ahrq.gov/issue/ensuring-correct-surgery
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - The ED team correctly decided that the patient would benefit from observation in the CCU. … Rosman and
colleagues found that clinicians correctly identified AD in more than 90% of patients if
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - The ED team correctly decided that the patient would benefit from observation in the CCU. … Rosman and colleagues found that clinicians correctly identified AD in more than 90% of patients if the
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psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Rethinking Root Cause Analysis
January 1, 2016
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
Annual Perspective 2016
Introduction
Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
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psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events
April 17, 2024 - Study
Putting the "action" in RCA(2): an analysis of intervention strength after adverse events.
Citation Text:
Zerillo JA, Tardiff SA, Flood D, et al. Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. Jt Comm J Qual Patient Saf. 2024;50(7):492-49…
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psnet.ahrq.gov/node/37009/psn-pdf
March 18, 2010 - Doing the "right" things to correct wrong-site surgery.
March 18, 2010
Patient Safety Advisory
https://psnet.ahrq.gov/issue/doing-right-things-correct-wrong-site-surgery
This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results
of other studies, and provides suggesti…
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia
Citation Text:
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Citation
…
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psnet.ahrq.gov/node/47536/psn-pdf
March 09, 2019 - Evaluation of wound photography for remote
postoperative assessment of surgical site infections.
March 9, 2019
Broman KK, Gaskill CE, Faqih A, et al. Evaluation of Wound Photography for Remote Postoperative
Assessment of Surgical Site Infections. JAMA Surg. 2019;154(2):117-124.
doi:10.1001/jamasurg.2018.3861.
htt…
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psnet.ahrq.gov/issue/patients-perceptions-importance-self-administered-correct-site-surgery-checklist-multisite
May 25, 2022 - Study
Patients' perceptions of importance for self-administered correct site surgery checklist: a multisite study.
Citation Text:
Krenzischek DA, Card E, Mamaril M, et al. Patients' perceptions of importance for self-administered correct site surgery checklist: a multisite study. J Peria…
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psnet.ahrq.gov/issue/biopsy-site-selfies-quality-improvement-pilot-study-assist-correct-surgical-site
August 02, 2015 - Study
Biopsy site selfies—a quality improvement pilot study to assist with correct surgical site identification.
Citation Text:
Nijhawan RI, Lee EH, Nehal KS. Biopsy site selfies--a quality improvement pilot study to assist with correct surgical site identification. Dermatol Surg. 2015;4…
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psnet.ahrq.gov/node/49791/psn-pdf
April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the
Preventable
April 1, 2017
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
The Case
An 84-year-old wo…
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psnet.ahrq.gov/node/45370/psn-pdf
July 27, 2016 - Correct use of inhalers: help patients breathe easier.
July 27, 2016
ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6.
https://psnet.ahrq.gov/issue/correct-use-inhalers-help-patients-breathe-easier
Patients and clinicians can make medication administration mistakes when new drug delivery mecha…
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psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
September 27, 2023 - same as simply repeating the order, as “read back” helps ensure the recipient has both heard the order correctly … and transcribed it correctly. 1 However, an ISMP member survey in 2017 revealed that the practice of
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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - Annual Perspective
Rethinking Root Cause Analysis
Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD | January 1, 2016
View more articles from the same authors.
Citation Text:
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. Rockville (MD): Age…
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psnet.ahrq.gov/node/49667/psn-pdf
October 01, 2012 - The order was written correctly in the electronic medical record (EMR) for phenytoin, 800 mg IV.