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psnet.ahrq.gov/node/867359/psn-pdf
December 18, 2024 - Therefore, all nurses should follow standardized processes
for tasks such as medication administration, lab
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - Discontinuities, Gaps, and Hand-Off Problems
(193)
Missed Care
(12)
Missed or Critical Lab
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psnet.ahrq.gov/node/853081/psn-pdf
August 30, 2023 - In Conversation with... Kathleen Sanford and Sue
Schuelke about Virtual Nursing
August 30, 2023
Sanford K, Schuelke S, Lee M, et al. In Conversation with.. Kathleen Sanford and Sue Schuelke about
Virtual Nursing. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schue…
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - SPOTLIGHT CASE
Total Parenteral Nutrition, Multifarious Errors
Citation Text:
Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
…
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psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
March 27, 2024 - SPOTLIGHT CASE
Hidden Heparins: HIT Happens
Citation Text:
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3…
-
psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - The only lab abnormality was a mild increase in her liver function tests which was attributed to her
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psnet.ahrq.gov/node/857061/psn-pdf
November 27, 2023 - In Conversation with... Joan Stanley about The Role of
Undergraduate Nursing Education in Patient Safety
November 27, 2023
Stanley J. In Conversation with.. Joan Stanley about The Role of Undergraduate Nursing Education in
Patient Safety . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-joa…
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psnet.ahrq.gov/node/865429/psn-pdf
April 24, 2024 - This
may take place in the electrophysiology lab or in the operating room where pacing via epicardial
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psnet.ahrq.gov/node/33859/psn-pdf
June 01, 2018 - If a patient comes in with a swollen right leg on a
Friday afternoon and a vascular ultrasound lab is
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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - SPOTLIGHT CASE
Despite Clues, Failed to Rescue
Citation Text:
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibTeX EndN…
-
psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - terms of organizations I work with, I’ll provide a specific example from a cardiac catheterization lab
-
psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - Therefore, all nurses should follow standardized processes for tasks such as medication administration, lab
-
psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - The Impact of Communication on Medication Errors
March 15, 2021
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors
The Case
A 93-year-old man with a history of chronic systolic heart failure…
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psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - thereby closing the loop.18 CLC is currently utilized by health systems to effectively report
critical lab
-
psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - She placed an electronic order for the lab tests to be performed, and the patient
had blood drawn the
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psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - These sessions can be performed in situ or in a dedicated simulation lab.
-
psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
December 01, 2017 - We can get the easy variables: the demographics and their lab values and even some of their comorbidities
-
psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - This may take place in the electrophysiology lab or in the operating room where pacing via epicardial
-
psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - The only lab abnormality was a mild increase in her liver function tests which was attributed to her
-
psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - thereby closing the loop. 18 CLC is currently utilized by health systems to effectively report critical lab