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psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - Right Electrocardiogram, Wrong Patient
March 25, 2020
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
The Cases
Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…
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psnet.ahrq.gov/node/49814/psn-pdf
December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation
Mishap
December 1, 2017
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
The Case
A 63-year-old man with a history of coronary…
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psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
March 04, 2020 - The Hidden Harms of Hand Sanitizer
Citation Text:
Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/web-mm/mark-my-tooth
June 01, 2014 - Accidental deaths, saved lives, and improved quality. N Engl J Med. 2005;353:1405-1409.
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psnet.ahrq.gov/node/49387/psn-pdf
February 01, 2003 - Reports of 355 transfusion-associated deaths: 1976 through 1985.
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psnet.ahrq.gov/node/49515/psn-pdf
July 01, 2006 - from peanut ingestion, 10 from tree nut ingestion, and 1 each
from fish and milk ingestion.(5) No deaths
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psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
December 15, 2024 - Ambulatory patients may experience ADEs at even higher rates, as illustrated by the dramatic increase in deaths
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psnet.ahrq.gov/node/49561/psn-pdf
May 01, 2008 - More than 500,000 cumulative deaths in the United States have occurred in persons with the acquired
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psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
February 05, 2020 - developed to prevent hypoxic gas mixtures, but all of them can fail under certain circumstances. 6 Deaths
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psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
April 26, 2023 - patient safety issue in the inpatient setting; research estimates between 10% and 13% of patient hospital deaths … had implemented a system that had a specific purpose, and it was extremely successful at preventing deaths
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psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
February 26, 2020 - Delayed Evaluation of Abdominal Pain in an Elderly Patient.
Citation Text:
Klimkiv L, Utter GH, Barnes DK. Delayed Evaluation of Abdominal Pain in an Elderly Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Citat…
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psnet.ahrq.gov/node/73902/psn-pdf
September 29, 2021 - An estimated 40,000 to 80,000 preventable
hospital deaths attributed to medical errors occur annually
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psnet.ahrq.gov/perspective/conversation-charles-ornstein
October 01, 2009 - Perhaps the two biggest were those leading to the deaths of Libby Zion in New York Hospital in 1984 and … It required the IOM report—particularly its made-for-TV analogy that the deaths from medical mistakes
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - Perhaps the two biggest were those leading to the deaths of Libby Zion in New York Hospital in 1984 and … It required the IOM report—particularly its made-for-TV analogy that the deaths from medical mistakes
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psnet.ahrq.gov/issue/validity-unplanned-admission-intensive-care-unit-measure-patient-safety-surgical-patients
May 26, 2021 - Study
Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients.
Citation Text:
Haller G, Myles PS, Wolfe R, et al. Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients. Anesthe…
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psnet.ahrq.gov/issue/potentially-inappropriate-medication-use-associated-increased-risk-incident-disability
October 19, 2022 - Study
Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults.
Citation Text:
Lockery JE, Collyer TA, Woods RL, et al. Potentially inappropriate medication use is associated with increased risk of incident disability in he…
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psnet.ahrq.gov/issue/sbar-improves-communication-and-safety-climate-and-decreases-incident-reports-due
June 01, 2016 - Study
SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective intervention study.
Citation Text:
Randmaa M, Mårtensson G, Swenne CL, et al. SBAR improves communication and safety climate and decreas…
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psnet.ahrq.gov/issue/strengths-and-weaknesses-diagnostic-process-endometriosis-patients-perspective-focus-group
March 06, 2019 - Study
Strengths and weaknesses in the diagnostic process of endometriosis from the patients' perspective: a focus group study.
Citation Text:
van der Zanden M, de Kok L, Nelen WLDM, et al. Strengths and weaknesses in the diagnostic process of endometriosis from the patients’ perspective:…
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psnet.ahrq.gov/issue/root-cause-analysis-serious-adverse-events-among-older-patients-veterans-health
August 02, 2015 - Study
Root cause analysis of serious adverse events among older patients in the Veterans Health Administration.
Citation Text:
Lee A, Mills PD, Neily J, et al. Root cause analysis of serious adverse events among older patients in the Veterans Health Administration. Jt Comm J Qual Patient…
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psnet.ahrq.gov/issue/outcomes-associated-nationwide-introduction-rapid-response-systems-netherlands
January 18, 2013 - Study
Outcomes associated with the nationwide introduction of rapid response systems in the Netherlands.
Citation Text:
Ludikhuize J, Brunsveld-Reinders AH, Dijkgraaf MGW, et al. Outcomes Associated With the Nationwide Introduction of Rapid Response Systems in The Netherlands. Crit Care …