-
psnet.ahrq.gov/node/43592/psn-pdf
November 23, 2016 - parents-and
In this study, health care providers and parents of children in a pediatric intensive care unit described
-
psnet.ahrq.gov/node/36494/psn-pdf
August 29, 2016 - medication-prescribing-errors-involving-route-administration
Error in medication prescribing is a well-described
-
psnet.ahrq.gov/node/46664/psn-pdf
December 22, 2018 - Perspective reviewed problematic prescribing practices that likely contribute to adverse events and
described
-
psnet.ahrq.gov/node/34784/psn-pdf
June 24, 2015 - Team dimensions, behaviors, and activities are
described in detail.
-
psnet.ahrq.gov/node/46833/psn-pdf
December 03, 2018 - A past WebM&M commentary described
the harms associated with inappropriate antibiotic use.
-
psnet.ahrq.gov/issue/ahrq-webmm-morbidity-mortality-rounds-web
December 24, 2008 - The site features expert analysis and discussion of anonymously submitted cases where an error was described
-
psnet.ahrq.gov/node/60542/psn-pdf
May 27, 2020 - electrolytes,
and absence of clinical decision support, almost certainly contributed to the error described … advising that processes for TPN management should be standardized.13 Many
of the TPN management processes described … safety and reduced medication errors across
clinical settings.15,16
To avoid errors such as the one described … staffing, for both day and night
shifts, is critical to help prevent medication errors such as the one described … resolution of such issues.25-29 Similar measures could be implemented at the hospital where the event
described
-
psnet.ahrq.gov/node/46618/psn-pdf
June 25, 2018 - A PSNet perspective described how surgical safety has evolved as a field.
-
psnet.ahrq.gov/node/44688/psn-pdf
February 23, 2018 - The authors also acknowledge potential challenges to
implementing the systems and process changes described
-
psnet.ahrq.gov/node/47334/psn-pdf
November 14, 2018 - This ethnographic
study described the safety experience of 26 medically complex British adults.
-
psnet.ahrq.gov/node/46665/psn-pdf
June 19, 2018 - The authors described various types of patient engagement in medication
management as sources of system
-
psnet.ahrq.gov/node/45500/psn-pdf
September 28, 2016 - This study described an iterative
consensus-building process which identified 12 indicators of potentially
-
psnet.ahrq.gov/node/45962/psn-pdf
April 24, 2018 - In this study, researchers described lessons learned
from creating a leadership role that bridges quality
-
psnet.ahrq.gov/node/38721/psn-pdf
June 25, 2009 - Past studies have
described workarounds and a near miss after similar implementations.
-
psnet.ahrq.gov/node/47612/psn-pdf
February 27, 2019 - unintended consequences of computerized provider order entry and clinical decision support are well-
described
-
psnet.ahrq.gov/node/46765/psn-pdf
April 04, 2018 - A variety of uses for health IT were
described, including integration of checklists and standardized
-
psnet.ahrq.gov/node/45967/psn-pdf
July 05, 2017 - A recent Annual Perspective discussed ongoing problems
with the root cause analysis process and described
-
psnet.ahrq.gov/node/46819/psn-pdf
January 27, 2019 - An Annual Perspective described other initiatives to reduce opioid-related harm.
-
psnet.ahrq.gov/node/34863/psn-pdf
June 12, 2007 - adapted many of the cases they previously published in the academic literature,
some cases previously described
-
psnet.ahrq.gov/node/37984/psn-pdf
August 13, 2008 - included having students shadow ICU nurses and also conduct a root cause analysis of
an error, are described