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psnet.ahrq.gov/issue/getting-havarti-moving-toward-patient-safety-obstetrics
October 19, 2022 - Commentary
Getting to havarti: moving toward patient safety in obstetrics.
Citation Text:
Veltman LL. Getting to havarti: moving toward patient safety in obstetrics. Obstet Gynecol. 2007;110(5):1146-1150.
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psnet.ahrq.gov/issue/prescription-error-process-defects-community-retail-pharmacy
October 19, 2022 - Study
Prescription for error: process defects in a community retail pharmacy.
Citation Text:
Witte D, Dundes L. Prescription for Error. J Patient Saf. 2008;3(4). doi:10.1097/pts.0b013e31815a613e.
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psnet.ahrq.gov/web-mm/multiple-missed-opportunities-suicide-risk-assessment-emergency-and-primary-care-settings
May 26, 2021 - Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings
Citation Text:
Erb JL, Shah SB, Schiff G. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - SPOTLIGHT CASE
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
Citation Text:
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - Annual Perspective
Diagnostic Errors
Urmimala Sarkar, MD; Kaveh Shojania, MD | January 1, 2014
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Citation Text:
Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - Recognition is often a first step to increasing clinicians' awareness of their possible effects, both
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psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health Care
Anita L. Tucker, DBA, MS | August 1, 2009
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Citation Text:
Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSN…
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psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
November 16, 2022 - issues may stimulate group learning that, in turn, lowers the chance of future medical errors, thereby increasing
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psnet.ahrq.gov/web-mm/elopement
July 14, 2010 - Given the recurring shortage of staff and the increasing complexity of patient care, use of technological
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - the provider directly with questions and requests (related to test result follow-up or otherwise), increasing
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - 2 ) Several developments in the health care system have exacerbated handoff problems, including the increasing
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psnet.ahrq.gov/node/33771/psn-pdf
August 22, 2014 - psnet.ahrq.gov//#ref20
diagnostic errors, the role of patients in improving safety, leveraging EHRs in increasing
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psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
December 23, 2020 - are now available and will continue to flourish with the advent of a certification process and the increasing
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psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - pre-configured limits), bar-code systems for medication administration and patient identification, and an increasing
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - solving of cases and in the calibration of nonanalytic decision-making processes over time and with increasing
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - process
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Ensure that all team members have a role/voice in the diagnostic process (1)
There has been increasing
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psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
January 29, 2021 - The increasing linguistic and cultural diversity of our country has led to the potential for communication
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - , 43% had them scanned into the EHR.( 4 ) Given the fragmentation of the health care system and the increasing
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psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
March 15, 2023 - Impaired cognitive function could lead to misuse of devices and chargers, increasing the risks of fires
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psnet.ahrq.gov/node/49648/psn-pdf
March 01, 2012 - or support to intervene on postdischarge issues may actually increase visits to the
ED, potentially increasing