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psnet.ahrq.gov/issue/impact-medical-errors-ninety-day-costs-and-outcomes-examination-surgical-patients
August 03, 2017 - December 22, 2010
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/issue/medicines-related-problems-mrps-originating-primary-care-settings-older-adults-systematic
March 04, 2015 - Review
Medicines related problems (MRPs) originating in primary care settings in older adults - a systematic review.
Citation Text:
Ude-Okeleke RC, Aslanpour Z, Dhillon S, et al. Medicines related problems (MRPs) originating in primary care settings in older adults - a systematic review.…
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psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - health care system more positive and focused not only on acute management but also on recovery and prevention … We need to be able to use digital to make sure that people don't fall off during the time in between … Innovations
Preventing Falls Through Patient and Family Engagement to Create Customized Prevention
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psnet.ahrq.gov/web-mm/failure-latch
November 27, 2012 - The infant was nursing frequently for 30–45 minutes at a time, was quite fussy, and tended to fall asleep … Center for Disease Control and Prevention Web site. Available at: www.cdc.gov/breastfeeding . 3. … Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention;
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psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
March 24, 2021 - Although the ED physicians felt he had simple bruising from the fall, they noted that he was in severe … soft tissue infections (as in this case, where it appeared the patient had simple bruising after his fall … Necrotizing fasciitis caused by Vibrio vulnificus : epidemiology, clinical findings, treatment and prevention
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psnet.ahrq.gov/issue/mix-wrong-route-administration-bladder-irrigation-intravenous-iv-infusions
March 27, 2005 - Government Resource
Mix-up (wrong route of administration) of bladder irrigation with intravenous (IV) infusions.
Citation Text:
Mix-up (wrong route of administration) of bladder irrigation with intravenous (IV) infusions. Veterans Affairs; National Center for Patient Safety
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psnet.ahrq.gov/issue/most-surgery-wrong-spot-done-spine-11-such-cases-found-state-2006
August 06, 2008 - Newspaper/Magazine Article
Most surgery in wrong spot done on spine: 11 such cases found in state since 2006.
Citation Text:
Most surgery in wrong spot done on spine: 11 such cases found in state since 2006. Smith S.
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psnet.ahrq.gov/issue/nurses-role-detecting-deterioration-ward-patients-systematic-literature-review
March 27, 2018 - Review
Nurses' role in detecting deterioration in ward patients: systematic literature review.
Citation Text:
Nurses' role in detecting deterioration in ward patients: systematic literature review. Odell M; Victor C; Oliver D.
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psnet.ahrq.gov/issue/organ-donors-surgery-death-sparks-questions
April 06, 2016 - Newspaper/Magazine Article
Organ donor's surgery death sparks questions.
Citation Text:
Organ donor's surgery death sparks questions. Cohen E. CNN. April 9, 2012.
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psnet.ahrq.gov/issue/mothers-face-broken-addiction-treatment-system
January 25, 2023 - Related Resources
‘I felt like I was dying’: how women with postpartum depression fall
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psnet.ahrq.gov/issue/medical-misdiagnoses-can-have-fatal-consequences
July 27, 2011 - Newspaper/Magazine Article
Medical misdiagnoses can have fatal consequences.
Citation Text:
Medical misdiagnoses can have fatal consequences. Olsen D. State Journal-Register. June 26, 2011.
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psnet.ahrq.gov/issue/alarm-interventions-during-medical-telemetry-monitoring-failure-mode-effects-analysis
March 18, 2010 - Special or Theme Issue
Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode & Effects Analysis.
Citation Text:
Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode & Effects Analysis. PA-PSRS Patient Saf Advis. March 2008;5(suppl rev):1-50. …
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psnet.ahrq.gov/issue/disease-management-mid-decade-evolution-toward-patient-safety
January 28, 2010 - Commentary
Disease management: a mid-decade evolution toward patient safety.
Citation Text:
Disease management: a mid-decade evolution toward patient safety. Heckinger E; Chappell H; Downes D; Fitzner K.
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psnet.ahrq.gov/issue/english-patient-safety-programme
September 02, 2020 - Special or Theme Issue
The English Patient Safety Programme.
Citation Text:
The English Patient Safety Programme. J Health Serv Research Policy. 2010;15(suppl 1):S1-S91.
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psnet.ahrq.gov/issue/perceptions-pediatric-hospital-safety-culture-united-states-analysis-2016-hospital-survey
January 19, 2022 - October 11, 2010
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/issue/how-effective-are-patient-safety-initiatives-retrospective-patient-record-review-study
March 18, 2013 - Study
Classic
How effective are patient safety initiatives? A retrospective patient record review study of changes to patient safety over time.
Citation Text:
Baines RJ, Langelaan M, de Bruijne M, et al. How effective are patient safety initiatives? A retrospect…
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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - The care of a person with dementia should be focused on prevention of delirium (for example, promotion … Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol. 2009;5:210-220.
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - year-old man with a history of untreated hypertension presented to the emergency department (ED) after a fall
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psnet.ahrq.gov/perspective/application-safety-ii-principles
August 28, 2024 - For example, most people don't fall or get a wrong site surgery.
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psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
August 28, 2024 - For example, most people don't fall or get a wrong site surgery.