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psnet.ahrq.gov/web-mm/check-twice-transport-once
March 15, 2023 - name, medical record number, date of birth, height, weight, isolation level, and code status to help correctly
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psnet.ahrq.gov/node/33601/psn-pdf
December 15, 2024 - failures in network
infrastructure can result in delays when patient context or status is not
timely or correctly
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psnet.ahrq.gov/node/867651/psn-pdf
February 26, 2025 - systems resulting in success and systems resulting in
failure function via two distinct modes: either correctly … within the sociotechnical system.4,19 In this way, every individual part of a system may function correctly
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psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
October 02, 2024 - systems resulting in success and systems resulting in failure function via two distinct modes: either correctly … within the sociotechnical system. 4 , 19 In this way, every individual part of a system may function correctly
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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/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
February 22, 2017 - observing and directing the execution of tasks or activities and making certain that everything is done correctly … observing and directing the execution of tasks or activities and making certain that everything is done correctly
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Emergency Department and with more left to give as part of the massive transfusion protocol that had been correctly
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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/perspective/role-bar-coding-and-smart-pumps-safety
September 01, 2008 - are definitely lots of opportunities to use barcode technology to make sure that lab specimens are correctly … patient safety impact but definitely could increase the efficiency of the hospital if it's implemented correctly
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psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation
March 27, 2024 - April 5, 2017
Are physician assistants able to correctly identify prescribing errors?
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psnet.ahrq.gov/web-mm/lethal-cap
December 19, 2018 - The pediatrician in this case correctly assumed that the parent might not understand simple written or
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psnet.ahrq.gov/node/40604/psn-pdf
December 30, 2014 - Errors in the administration of intravenous medications in
hospital and the role of correct procedures and nurse
experience.
December 30, 2014
Westbrook JI, Rob MI, Woods A, et al. Errors in the administration of intravenous medications in hospital
and the role of correct procedures and nurse experience. BMJ Qual …
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psnet.ahrq.gov/node/33582/psn-pdf
September 15, 2024 - In cases in which the trigger correctly identifies an adverse event, causative factors can be
determined
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psnet.ahrq.gov/primer/electronic-health-records
March 15, 2025 - failures in network infrastructure can result in delays when patient context or status is not timely or correctly
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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/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/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
December 20, 2023 - for harm, if the patient and her family had received a medication that they were not trained to use correctly
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psnet.ahrq.gov/web-mm/x-ray-flip
August 10, 2019 - A correctly labeled follow-up chest x-ray showed persistent pneumothorax on the patient's left and the
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psnet.ahrq.gov/primer/detection-safety-hazards
March 30, 2022 - In cases in which the trigger correctly identifies an adverse event, causative factors can be determined
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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…