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psnet.ahrq.gov/web-mm/hold-tpa
August 09, 2023 - Hold the tPA
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psnet.ahrq.gov/web-mm/hold-order
April 01, 2017 - The intern wrote the following order: "Hold DDAVP tonight." … Why do errors occur in association with hold orders? … and the hold order and/or corresponding parameters are omitted When hold orders are not adequately … Providers should avoid the use of hold orders unless absolutely necessary. … Example Hold Order.
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psnet.ahrq.gov/issue/holding-out-apology
April 25, 2024 - Commentary
Holding out for an apology.
Citation Text:
Holding out for an apology. BMJ. 2018;363:k3033. doi:10.1136/bmj.k3033.
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psnet.ahrq.gov/issue/do-not-put-medication-safety-hold-boarded-patients
January 21, 2009 - Commentary
Do not put medication safety "on hold" with boarded patients. … Do not put medication safety "on hold" with boarded patients. … Do not put medication safety "on hold" with boarded patients.
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psnet.ahrq.gov/issue/quality-and-safety-medical-care-what-does-future-hold
September 18, 2019 - Commentary
Quality and safety in medical care: what does the future hold? … Quality and safety in medical care: what does the future hold? … Quality and safety in medical care: what does the future hold?
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psnet.ahrq.gov/issue/mgh-halts-pediatric-program-heart-surgeries-hold-after-errors
September 10, 2014 - Newspaper/Magazine Article
MGH halts a pediatric program: Heart surgeries on hold
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psnet.ahrq.gov/issue/health-care-information-technology-vendors-hold-harmless-clause-implications-patients-and
May 29, 2019 - Commentary
Health care information technology vendors' "hold harmless" clause: implications … Health care information technology vendors' "hold harmless" clause: implications for patients and clinicians … Health care information technology vendors' "hold harmless" clause: implications for patients and clinicians … July 15, 2015
Healthcare scandals and the failings of doctors: do official inquiries hold
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psnet.ahrq.gov/issue/temporarily-holding-medication-orders-safely-order-prevent-patient-harm
March 14, 2023 - alerts, assigning one prescriber to oversee medication reconciliation , and instituting a policy on hold
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psnet.ahrq.gov/issue/healthcare-scandals-and-failings-doctors-do-official-inquiries-hold-profession-account
November 13, 2019 - Review
Healthcare scandals and the failings of doctors: do official inquiries hold
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psnet.ahrq.gov/issue/incentives-patient-safety-holding-healthcare-executives-accountable
June 29, 2005 - Commentary
Incentives for patient safety: holding healthcare executives accountable.
Citation Text:
ECRI Institute. Risk Management Reporter. August 2008;27:1-10.
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psnet.ahrq.gov/training-catalog/ashrm-2021-annual-conference
January 01, 2021 - for Healthcare Risk Management (ASHRM)
Event Description: Conference intends to hold
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psnet.ahrq.gov/glossary/active-error-or-active-failure
September 13, 2021 - Active Error (or Active Failure)
September 13, 2021
Anonymous (not verified)
The terms active and latent as applied to errors were coined by Reason . Active errors occur at the point of contact between a human and some aspect of a larger system (e.g., a human machine interface). They are generally readily …
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psnet.ahrq.gov/taxonomy/term/3451
Active Error (or Active Failure)
The terms active and latent as applied to errors were coined by Reason . Active errors occur at the point of contact between a human and some aspect of a larger system (e.g., a human–machine interface). They are generally readily apparent (e.g., pushing an incorrect button, ign…
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psnet.ahrq.gov/issue/excellent-review-scheme-critical-incidents-insufficient-revalidation
May 18, 2022 - April 17, 2019
Healthcare scandals and the failings of doctors: do official inquiries hold
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psnet.ahrq.gov/web-mm/dropping-new-lows
May 01, 2016 - The nurses caring for the patient would often "hold" the morning or evening doses of insulin if his blood … the hospital, concluding that holding orders should be avoided unless absolutely necessary and that hold … Algorithm to Guide Assessment and Interventions When Nutrition Is Unexpectedly on Hold … Retention Dilemma
November 1, 2006
WebM&M Cases
Hold
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psnet.ahrq.gov/issue/vanderbilt-center-patient-and-professional-advocacy
March 02, 2022 - from a culture of safety, tactics to address disruptive behaviors , and organizational actions to hold
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psnet.ahrq.gov/print/pdf/node/842920
December 14, 2022 - Due to
suicidal ideation, he was placed on safety hold... … Due to
suicidal ideation, he was placed on safety hold...
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psnet.ahrq.gov/issue/measuring-patient-safety-events-opportunities-and-challenges
February 15, 2023 - March 27, 2019
Healthcare scandals and the failings of doctors: do official inquiries hold
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psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
March 29, 2023 - anxiety disorder, in a long-term stable relationship, was placed on 72-hour involuntary psychiatric hold … evaluation, the ED staff decided to admit the patient for observation (still on involuntary psychiatric hold … should have been returned to the ED immediately, been placed under an additional involuntary psychiatric hold … jail rather than escorted back to the ED, since he was most recently under involuntary psychiatric hold
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psnet.ahrq.gov/taxonomy/term/3488
December 12, 2020 - Latent Error (or Latent Condition)
The terms active and latent as applied to errors were coined by Reason . Latent errors (or latent conditions) refer to less apparent failures of organization or design that contributed to the occurrence of errors or allowed them to cause harm to patients. For instance, whereas …