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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - As another example, the American Society for Clinical Laboratory Science has proposed a patient safety
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psnet.ahrq.gov/web-mm/ectopic-or-not
March 27, 2024 - Accordingly, algorithms have been developed that rely on laboratory values, and in certain instances,
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psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
October 30, 2024 - including composite scores for chronic severity of illness (Comorbidity Point Score, version 2, and Laboratory-Based
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psnet.ahrq.gov/node/865778/psn-pdf
May 29, 2024 - The patient’s laboratory results were notable for
acute kidney injury and metabolic acidosis, with an
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - This fluid was suctioned out and sent to the laboratory for analysis.
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psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
June 01, 2016 - December 23, 2020
Impact of non-interruptive medication laboratory monitoring alerts
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psnet.ahrq.gov/periodic-issue/periodic-issue-469
December 31, 2024 - The commentary highlights how the misinterpretation of a common laboratory complication can lead to incorrect
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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - The commentary highlights how the misinterpretation of a common laboratory complication can lead to incorrect
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psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - and nursing homes.( 2-4 ) Examples of wrong patient errors include medications, radiology tests, and laboratory
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psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
November 27, 2019 - He then experienced sudden cardiac arrest and was emergently taken to the cardiac catheterization laboratory
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psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
September 01, 2012 - The laboratory results showed a sharp drop in her blood count, consistent with postprocedural bleeding
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - the importance of the
need to not only understand verbal instructions, translate numbers such as in laboratory
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psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
July 02, 2019 - The influence of tall man lettering on drug name confusion: a laboratory-based investigation in the UK
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psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
February 20, 2019 - play in a clinical setting.( 11 )
Studies reporting superhuman machine learning performance in a laboratory
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psnet.ahrq.gov/web-mm/missed-pneumonia
June 01, 2005 - Laboratory test results, including CBC and BMP, were unremarkable.
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psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
September 01, 2012 - reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories
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psnet.ahrq.gov/node/33724/psn-pdf
February 01, 2012 - hesitant to let a trainee do
something for the first time, we can do with either simulation or skills laboratories
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psnet.ahrq.gov/node/33672/psn-pdf
September 01, 2008 - What other things, including
laboratories, pathology, patient transport, or right side surgery, can
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.434_slideshow.ppt
February 01, 2018 - PowerPoint Presentation
Spotlight
Signout Fallout
1
Source and Credits
This presentation is based on the February 2018
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH, Harvard M…
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - events; inadequate communication, including problems with care transitions or reporting and follow-up of laboratory … One of the projects that we did with AHRQ was developing and strengthening a patient safety laboratory … patient and clinician (1) had a shared decision about getting a test, (2) getting the blood test, (3) the laboratory … doing the test, (4) the laboratory reporting the test result back to the practice, (5) the result reported