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psnet.ahrq.gov/issue/orders-file-no-labs-drawn-investigation-machine-and-human-errors-caused-interface
November 01, 2017 - Commentary
Orders on file but no labs drawn: investigation of machine and human errors … Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy … Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy
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psnet.ahrq.gov/issue/dennis-quaid-files-suit-over-drug-mishap
October 14, 2020 - Newspaper/Magazine Article
Dennis Quaid files suit over drug mishap.
Citation Text:
Ornstein C. Los Angeles Times. September 16, 2014.
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psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
May 27, 2020 - Upon further review, it was discovered a new file had been created for this chronic PN patient by the … home infusion pharmacy; the PN formula in this file was transcribed erroneously without sodium acetate … As demonstrated in this case, an error of omission made when transcribing a new PN file by the home infusion
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psnet.ahrq.gov/issue/suit-filed-over-virginia-mason-medical-centers-error
July 05, 2006 - Newspaper/Magazine Article
Suit filed over Virginia Mason Medical Center's error.
Citation Text:
Ostrom CM
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April 3, 2005
Os…
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psnet.ahrq.gov/issue/be-sued-less-doctors-should-consider-talking-patients-more
March 06, 2005 - associated with medical malpractice, how the same physicians tend to get sued, and reasons patients file
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psnet.ahrq.gov/issue/application-root-cause-analysis-malpractice-claim-files-related-diagnostic-failures
January 26, 2011 - Study
Application of root cause analysis on malpractice claim files related to diagnostic failures.
Citation Text:
van Noord I, Eikens MP, Hamersma AM, et al. Application of root cause analysis on malpractice claim files related to diagnostic failures. BMJ Qual Saf. 2010;19(6). doi:10.…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.359_slideshow.ppt
October 01, 2015 - PowerPoint Presentation
Spotlight
The Risks of Absent Interoperability:
Medication-Induced Hemolysis in a Patient With a Known Allergy
1
This presentation is based on the October 2015
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/
CME credit is available
Commentary by: Jacob Reider,…
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psnet.ahrq.gov/issue/medical-malpractice-claims-members-uniformed-services
November 17, 2021 - This United States rule outlines the standards that enable members of the armed forces to file claims
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psnet.ahrq.gov/issue/parents-sue-over-babies-heparin-overdoses-infants-were-given-too-much-heparin-methodist
April 14, 2010 - Newspaper/Magazine Article
Parents sue over babies' heparin overdoses: infants were given too much heparin at Methodist Hospital.
Citation Text:
Higgins W.
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psnet.ahrq.gov/issue/negligent-care-and-malpractice-claiming-behavior-utah-and-colorado
March 27, 2005 - Study
Classic
Negligent care and malpractice claiming behavior in Utah and Colorado.
Citation Text:
Studdert DM, Thomas EJ, Burstin HR, et al. Negligent care and malpractice claiming behavior in Utah and Colorado. Med Care. 2000;38(3):250-60.
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psnet.ahrq.gov/Information/Privacy
A persistent cookie is a more permanent line of text that gets saved by your browser to a file on your
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psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - Spotlight
Spotlight
The Consequences of Miscommunication
Regarding a Possible Artifact
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Kriti Gwal, MD
o AHRQ WebM&M Edit…
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psnet.ahrq.gov/issue/exploring-factors-drive-clinical-negligence-claims-stated-preferences-those-who-have
April 08, 2020 - This study found that individuals are less likely to file a malpractice claims after a patient safety
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psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
January 01, 2021 - Spotlight
Spotlight
An Inadvertent Bolus of Norepinephrine
Source and Credits
• This presentation is based on the May 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarina Fazio, PhD, RN, Emma Blackmon, PhD,
RN, Amy Doroy, PhD,…
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psnet.ahrq.gov/issue/claiming-behaviour-no-fault-system-medical-injury-descriptive-analysis-claimants-and-non
February 15, 2006 - They also determined that poor, elderly, or minority patients were least likely to file a claim.
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psnet.ahrq.gov/issue/patient-safety-stories-project-utilizing-narratives-resident-training
July 02, 2014 - Although physicians historically do not file voluntary error reports , this study of internal medicine
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psnet.ahrq.gov/issue/use-cpoe-log-analysis-physicians-behavior-when-responding-drug-duplication-reminders
October 26, 2016 - This study used a log file within a computerized physician order entry (CPOE) system to understand
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psnet.ahrq.gov/issue/lessons-learnt-incidents-reported-postgraduate-trainees-dutch-general-practice-prospective
February 23, 2011 - misses scored more highly on objective performance assessments compared with their peers who did not file
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psnet.ahrq.gov/issue/reporting-health-information-technology-system-related-patient-safety-incidents-effects
August 19, 2020 - Approximately half of respondents indicated that they did not file a report when encountering an HIT-related
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psnet.ahrq.gov/issue/rates-and-types-events-reported-established-incident-reporting-systems-two-us-hospitals
March 04, 2009 - Study
Rates and types of events reported to established incident reporting systems in two US hospitals.
Citation Text:
Nuckols TK, Bell D, Liu H, et al. Rates and types of events reported to established incident reporting systems in two US hospitals. Qual Saf Health Care. 2007;16(3):16…