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psnet.ahrq.gov/web-mm/cups-error
January 12, 2011 - medication cups represents an understandable and almost predictable event—a veritable accident waiting to happen
-
psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
January 01, 2020 - medication errors and adverse events through hard stops when
maximum doses are exceeded
• This did not happen
-
digital.ahrq.gov/ahrq-funded-projects/assess-risk-wrong-patient-errors-emr-allows-multiple-records-open
January 01, 2023 - “Placing orders on the wrong patient should never happen.
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psnet.ahrq.gov/web-mm/lp-or-not-lp
February 01, 2018 - psychologists have long known that errors in the completion of routine tasks are particularly likely to happen
-
psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-intervention-innovation
July 23, 2024 - It’s also important to emphasize that making significant change is a gradual process that doesn’t happen
-
effectivehealthcare.ahrq.gov/sites/default/files/pdf/major-depressive-disorder_consumer.pdf
September 01, 2016 - professional said you have any of these conditions:
» Seasonal affective disorder (depression symptoms that happen
-
psnet.ahrq.gov/web-mm/patient-mix
December 01, 2007 - It is also important to remember that these 'flukes' do happen, and the thousands of medication administrations
-
psnet.ahrq.gov/node/72693/psn-pdf
January 29, 2021 - Similar adverse drug events related to different drug concentrations in same-size ampules also happen
-
psnet.ahrq.gov/node/49423/psn-pdf
November 01, 2003 - Surgical tools left in five patients: UW surgeons take precautions to ensure it doesn’t happen
again
-
psnet.ahrq.gov/node/851158/psn-pdf
June 28, 2023 - Ultimately, this case is an excellent example of what can happen when best
practices are not followed
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/best-practices-survey-administration-webcast-sorra.pdf
January 01, 2024 - year’s safety
improvements: The survey
begins during patient
safety awareness week
Safety doesn’t
happen
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/qi-action-slides.pptx
April 01, 2022 - more authority
Communication about error: 38.9%
Driver of score: We are informed about errors that happen
-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-cord-prolapse.html
July 01, 2023 - Being aware of what is going on and what is likely to happen next.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/026-why-choose-cusp.pptx
April 01, 2025 - Defect: Any clinical or operational event or situation that you do not want to have happen again.3
Emphasizes
-
psnet.ahrq.gov/node/49476/psn-pdf
March 02, 2005 - If he did not, how could this happen?
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.323_slideshow.ppt
May 01, 2014 - medication reconciliation
There are many barriers and true robust medication reconciliation often does not happen
-
psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - Every patient
is different and things happen in the hospitalization, so to get the acute situation under
-
psnet.ahrq.gov/issue/when-surgeon-too-old-operate
February 12, 2016 - Newspaper/Magazine Article
When is the surgeon too old to operate?
Citation Text:
When is the surgeon too old to operate? Span P. New York Times. February 1, 2019.
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psnet.ahrq.gov/issue/patient-safety-article-collection
December 19, 2012 - Multi-use Website
Patient Safety Article Collection.
Citation Text:
Patient Safety Article Collection. American Patient Rights Association. 2012-2022.
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psnet.ahrq.gov/issue/mistaking-error
July 06, 2011 - Book/Report
Mistaking error.
Citation Text:
Mistaking error. Cook RI, Woods DD. Chapter in: Youngberg BJ, Hatlie, MJ, ed. Patient Safety Handbook, Sudbury, MA: Jones and Bartlett; 2004.
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