-
psnet.ahrq.gov/issue/inadvertent-administration-magnesium-sulfate-through-epidural-catheter-report-and-analysis
March 06, 2019 - January 7, 2015
Strategies to prevent healthcare-associated infections through hand hygiene
-
psnet.ahrq.gov/periodic-issue/periodic-issue-437
April 10, 2024 - Studies focused on a variety of challenges such as hand hygiene and healthcare-associated infections.
-
psnet.ahrq.gov/node/49512/psn-pdf
May 01, 2006 - Right? Left? Neither!
May 1, 2006
Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-left-neither
Case Objectives
Appreciate the role of Reason's Swiss Cheese Model in medical errors
Understand the process of analyzing a single error
Provide suggestions for …
-
psnet.ahrq.gov/node/50612/psn-pdf
October 30, 2019 - without an established trainee relationship to thoroughly assess the learner's capabilities, the task
at hand
-
psnet.ahrq.gov/web-mm/2-week-itch
June 16, 2019 - June 16, 2019
Perspective
Innovations in Promoting Hand
-
psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
November 21, 2021 - Hand-off communication does affect patient safety. Plast Surg Nurs. 2009;29:266-270.
-
psnet.ahrq.gov/web-mm/two-pills-same-drug
May 27, 2011 - majority of potential ADEs occur during ordering.( 6 ) In most U.S. hospitals, clinicians write orders by hand
-
psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
December 21, 2018 - Care Units
Health Care Executives and Administrators
Critical Care
Discontinuities, Gaps, and Hand-Off
-
psnet.ahrq.gov/web-mm/glucose-roller-coaster
February 02, 2022 - March 21, 2009
WebM&M Cases
On the Other Hand
-
psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
February 01, 2014 - September 1, 2007
WebM&M Cases
On the Other Hand
-
psnet.ahrq.gov/web-mm/electronic-err
April 01, 2014 - Physicians
Facility and Group Administrators
Information Professionals
Discontinuities, Gaps, and Hand-Off
-
psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
January 24, 2018 - Disentangling quality and safety indicator data: a longitudinal, comparative study of hand
-
psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
July 02, 2019 - March 21, 2009
WebM&M Cases
On the Other Hand
-
psnet.ahrq.gov/web-mm/triage-time-bomb
September 01, 2008 - most sensitive in identifying patients who subsequently required hospitalization.( 8 ) On the other hand
-
psnet.ahrq.gov/web-mm/or
August 22, 2013 - About The Topic
Operating Room
Physicians
Nurses
Surgery
Discontinuities, Gaps, and Hand-Off
-
psnet.ahrq.gov/node/49399/psn-pdf
May 01, 2003 - On the other hand, if the hCG levels do not fall, or
instead continue to rise, the diagnosis of ectopic
-
psnet.ahrq.gov/node/50389/psn-pdf
September 25, 2019 - team
members deferred to the primary oncologist—and thus overemphasized the oncologic emergency at
hand—rather
-
psnet.ahrq.gov/node/49775/psn-pdf
November 01, 2016 - On the other hand, we have
chosen to couple our warfarin order with an order for prothrombin time/international
-
psnet.ahrq.gov/node/49728/psn-pdf
March 01, 2015 - entered correctly, a BCMA alert likely would have signaled a nurse that the wrong
medication was in hand
-
psnet.ahrq.gov/node/60543/psn-pdf
May 27, 2020 - Hand (N Y). 2012; 7(2):229?
232. doi:10.1007/s11552-012-9405-5
10.