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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - intravenous hydromorphone was also started postoperatively, which was transitioned to oral oxycodone (up … hemodialysis, but a conservative approach of 100 mg by mouth three times weekly after hemodialysis, up
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psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
February 26, 2020 - The reason for the triage delay is unclear, but triage can easily back up when the ED is busy, given … increased patient satisfaction. 16-18 To avoid poor patient outcomes, ED staff should be prepared to up-triage
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psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
May 01, 2014 - But we have more than 12,000 employees in our institution—so, how would you like to follow all employees … We performed a literature review (in press) of 48 studies published up to the end of last year. … To back this up, there are studies where system change has been implemented as the only parameter to
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psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
May 01, 2014 - But we have more than 12,000 employees in our institution—so, how would you like to follow all employees … We performed a literature review (in press) of 48 studies published up to the end of last year. … To back this up, there are studies where system change has been implemented as the only parameter to
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psnet.ahrq.gov/node/855058/psn-pdf
October 31, 2023 - levels to understand workplace violence, to know when and how
to take appropriate actions, and to follow … patient safety culture is a culture where
people feel psychologically safe working, where they can speak up
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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
August 30, 2023 - agility and determination to lead, convene, identify, and conduct small tests of change and to ramp up … Hartford Foundation , we set up a rapid response network specific to nursing homes to offer brief calls … improvement, and it’s prompted a lot of important conversation that they may never have been addressed up
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psnet.ahrq.gov/perspective/conversation-georgia-galanou-luchen-pharm-d
October 24, 2021 - Sometimes verification requires picking up the phone and calling the prescriber or patient. … Professional education in these instances is so important, ensuring that you're up to speed with the
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psnet.ahrq.gov/web-mm/death-pca
January 06, 2017 - First, there was failure in the independent double check during the device set up.
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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - January 26, 2022
WebM&M Cases
Medication Mix-Up
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psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
March 01, 2009 - on his interpretation of these instructions, the patient revealed that he had been regularly taking up
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - Right Patient, Wrong Sample
Citation Text:
Astion ML. Right Patient, Wrong Sample. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - He had disturbed nighttime sleep and occasionally got up at night, showered, and dressed, before asking
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - of Cancer
July 31, 2023
WebM&M Cases
Coming up
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psnet.ahrq.gov/node/49810/psn-pdf
November 01, 2017 - The patient appeared to be sleeping but woke up when the nurse came in the
room.
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - In the current case, perhaps frontline caregivers would have spoken up about fall risk or pressure ulcer
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psnet.ahrq.gov/node/866343/psn-pdf
December 31, 2024 - clear from the case report what
factors drove the decision to start with a crystalloid bolus, but up
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psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
January 29, 2021 - WebM&M Cases
Unintentional Ketamine Overdose in the Operating Room – Mixing Up
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psnet.ahrq.gov/perspective/conversation-cheryl-jones-about-addressing-workplace-violence-and-creating-safer
October 31, 2023 - all levels to understand workplace violence, to know when and how to take appropriate actions, and to follow … patient safety culture is a culture where people feel psychologically safe working, where they can speak up … conducted at the University of Michigan estimated that the incidence of workplace violence could be up
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psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
October 31, 2023 - conducted at the University of Michigan estimated that the incidence of workplace violence could be up … all levels to understand workplace violence, to know when and how to take appropriate actions, and to follow … patient safety culture is a culture where people feel psychologically safe working, where they can speak up
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psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
September 01, 2012 - There's strong pressure on hospitals to follow the Willie Sutton theory of cost containment, which is … What we saw through the 1990s was length of stay going down, patient acuity going up, and nursing not