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psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
June 16, 2021 - Many of the steps and techniques described above fall under the field of medication safety engineering
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psnet.ahrq.gov/node/49782/psn-pdf
January 01, 2017 - starting vasopressors peripherally, or, alternatively, why
they allowed the patient's blood pressure to fall
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psnet.ahrq.gov/node/49754/psn-pdf
February 01, 2016 - Use of designated nurse PICC teams and CLABSI prevention
practices among U.S. hospitals: a survey-based
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psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - Baffled by Botulinum Toxin
Citation Text:
Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/33712/psn-pdf
June 01, 2011 - Or are there ways to prospectively
anticipate that something is likely to fall off the back of the truck
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psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
July 20, 2016 - starting vasopressors peripherally, or, alternatively, why they allowed the patient's blood pressure to fall
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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - Paulozzi LJ, Strickler GK, Kreiner PW, Koris CM; Centers for Disease Control and Prevention (CDC).
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psnet.ahrq.gov/issue/indiana-medical-error-reporting-system-final-report-2015
July 15, 2009 - Multi-use Website
Indiana Medical Error Reporting System.
Citation Text:
Indiana Medical Error Reporting System. Indianapolis, IN: Indiana State Department of Health.
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psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement
Eric Thomas, Sarah Mossburg, Merton Lee | September 24, 2024
Also Read the Essay
View more articles from the same authors.
Citatio…
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - In comparison, the recommended dose of rivaroxaban for the prevention of stroke in patients with atrial … dose depends on several factors including the indication (atrial fibrillation, VTE treatment, or VTE prevention … (4) assist with cost issues, especially for Medicare patients whose insurance may change yearly or fall
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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - know health care delivery backwards and forwards—are themselves not immune from seeing these issues fall
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psnet.ahrq.gov/node/861738/psn-pdf
January 31, 2024 - Human errors and their prevention in healthcare. … Human errors and their prevention in healthcare.
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psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
January 01, 2024 - Human errors and their prevention in
healthcare. … Human errors and their prevention in healthcare.
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psnet.ahrq.gov/web-mm/check-twice-transport-once
March 15, 2023 - Hole
October 1, 2003
WebM&M Cases
Another Fall
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - Open wider: Failure to use an interpreter results in
fractured teeth and hypoxia during a simple elective
operation.
December 14, 2022
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia
during a simple elective operation. PSNet [internet]. 2022.
https://psnet.ah…
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psnet.ahrq.gov/web-mm/pregnant-danger
January 12, 2011 - In the present case, the patient would fall into Category V (medical complaint not related to pregnancy
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psnet.ahrq.gov/node/866622/psn-pdf
August 28, 2024 - For example,
most people don't fall or get a wrong site surgery.
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psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
November 16, 2022 - What are you doing with infection prevention? … We’ve also done a lot of work in infection prevention. … process was focused on the particular patient population of older adults who come to the ED with a fall … Related Resources
Perspectives on Safety
Suicide Prevention … Interview
In Conversation with Edwin Boudreaux about Suicide Prevention
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psnet.ahrq.gov/perspective/safety-across-board
August 31, 2020 - When I began looking for my next position in 2005/2006, I was already very focused on safety, prevention … December 18, 2024
Patient Safety Innovations
Suicide Prevention