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psnet.ahrq.gov/issue/intravenous-chemotherapy-compounding-errors-follow-pan-canadian-observational-study
March 18, 2011 - May 18, 2022
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/issue/finding-blunders-thyroid-testing-experience-newborns
March 04, 2020 - September 20, 2023
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/web-mm/dropping-new-lows
December 18, 2024 - SPOTLIGHT CASE
Dropping to New Lows
Citation Text:
Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/33569/psn-pdf
June 15, 2024 - Readmissions and Adverse Events After Discharge
June 15, 2024
Readmissions and Adverse Events After Discharge. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
t…
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - The Case A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture
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psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
August 01, 2009 - May 8, 2017
Perspective
How Does Infection Prevention Fit … Journal Article
Study
Catching those who fall
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psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - male with a history of chronic opioid use, anxiety disorder, and major depression presented after a fall … specifically, post-operative pain management encompasses a balance of adequate pain control and the prevention … Implementing standardized sedation assessments, such as POSS, aids nurses in the prediction and prevention
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psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
May 01, 2008 - After the fall, a CT scan revealed a fracture of the cervical spine, which required spinal fusion surgery … in patients with alcohol dependence in a double-blind, placebo-controlled trial: the role of patient prevention … opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention
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psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
April 04, 2018 - serious adverse effects including death.( 1,19 ) In 2012, the Centers for Disease Control and Prevention … Patients with concurrent substance abuse and high risk for abusing the prescription opiates fall under … Centers for Disease Control and Prevention. … Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. … Centers for Disease Control and Prevention.
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psnet.ahrq.gov/node/49816/psn-pdf
January 01, 2018 - After the fall, a CT scan revealed a fracture of the cervical spine, which required
spinal fusion surgery … patients
with alcohol dependence in a double-blind, placebo-controlled trial: the role of patient prevention
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psnet.ahrq.gov/node/860050/psn-pdf
January 04, 2024 - Children’s Bureau Learning and Coordination Center (CBLCC), Prevent Child Abuse
America, The Child Abuse Prevention
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psnet.ahrq.gov/node/49581/psn-pdf
March 21, 2009 - Organizations often develop error prevention strategies following a serious event that focus solely on … The
error occurs when individuals fall victim to the flaws within the system and mistakes are made.
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - Lucian Leape highlighted the issue and presented a framework for error analysis and prevention that is … include: Preventable adverse events: those due to error or failure to apply an accepted strategy for prevention
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psnet.ahrq.gov/node/846171/psn-pdf
July 26, 2022 - .16,17
Due to the high incidence of delirium among hospitalized patients, strategies for surveillance, prevention … ,
and management should be implemented for older adults.16,17 Delirium prevention and care bundles, … delirium or worsening agitation.19
Currently, there are no recommended pharmacologic treatments for prevention
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psnet.ahrq.gov/node/33861/psn-pdf
July 01, 2018 - The thoracic surgeon said
I "shouldn't fall on my sword" because the delay didn't really change her … We have annual conferences, the 11th is coming up
this fall in New Orleans.
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psnet.ahrq.gov/issue/optimizing-smart-pump-technology-increasing-critical-safety-alerts-and-reducing-clinically
February 12, 2014 - July 26, 2023
Balancing safety, comfort, and fall risk: an intervention to limit opioid
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psnet.ahrq.gov/issue/adverse-event-screening-tool-based-routinely-collected-hospital-acquired-diagnoses
July 23, 2008 - December 31, 2012
6-PACK programme to decrease fall injuries in acute hospitals: cluster
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psnet.ahrq.gov/issue/prescription-opioid-crisis-role-anaesthesiologist-reducing-opioid-use-and-misuse
November 16, 2022 - July 1, 2019
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/issue/evidence-anchoring-bias-during-physician-decision-making
November 17, 2021 - Study
Evidence for anchoring bias during physician decision-making.
Citation Text:
Ly DP, Shekelle PG, Song Z. Evidence for anchoring bias during physician decision-making. JAMA Intern Med. 2023;183(8):818-823. doi:10.1001/jamainternmed.2023.2366.
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psnet.ahrq.gov/issue/fumbled-handoffs-one-dropped-ball-after-another
April 10, 2024 - Journal Article
Study
Catching those who fall