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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851099/psn-pdf
    June 28, 2023 - Misconnection Leading to Arterial Thrombosis June 28, 2023 Bohringer C, Lee G. … Misconnection Leading to Arterial Thrombosis. PSNet [internet]. 2023. … https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis The Case A 55-year-old man … The Commentary https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis by Christian … are also associated with pain on arterial injection, they are much less likely to cause thrombosis leading

  2. Risk of medication errors at hospital discharge and barriers to problem resolution. | PSNet

    psnet.ahrq.gov/issue/risk-medication-errors-hospital-discharge-and-barriers-problem-resolution
    November 03, 2015 - authors reviewed discharge medication records for elderly patients to assess documentation problems leading

  3. Survey results reveal tubing misconnections are common and underreported—Parts I and II. | PSNet

    psnet.ahrq.gov/issue/survey-results-reveal-tubing-misconnections-are-common-and-underreported-parts-i-and-ii
    December 18, 2024 - November 8, 2023 WebM&M Cases Misconnection Leading to

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40309/psn-pdf
    April 22, 2011 - Brent James—one of the nation's leading physician quality improvement experts—discussed his use of change

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45731/psn-pdf
    September 29, 2017 - example, in the case of breast cancer, screening may detect lesions that are not clinically significant, leading

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46197/psn-pdf
    September 24, 2017 - A past PSNet interview featured Dave deBronkart, a leading advocate for engaging patients in their care

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43571/psn-pdf
    October 01, 2014 - evidence that walkrounds improved safety culture, this practice became widely endorsed by AHRQ and other leading

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41706/psn-pdf
    November 08, 2012 - An AHRQ WebM&M commentary discusses a case of medication error leading to a preventable readmission.

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41795/psn-pdf
    September 07, 2016 - Although the details leading to the voluntary facility shutdown were not transparent, the authors suggest

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40842/psn-pdf
    September 24, 2016 - A case of an interruption leading to a medication error is discussed in this AHRQ WebM&M commentary.

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44586/psn-pdf
    June 21, 2016 - important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33578/psn-pdf
    September 07, 2019 - Newborns in a neonatal intensive care unit are given full-dose heparin instead of low-dose flushes, leading … workarounds-barcode-medication-administration-systems-their-occurrences-causes-and-threats https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis

  13. Rapid Response Systems | PSNet

    psnet.ahrq.gov/curated-library/rapid-response-systems
    September 07, 2019 - the Quiz Spotlight Case Delay in Appropriate Diagnosis and Treatment Leading … Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism David Barnes

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44372/psn-pdf
    June 21, 2016 - These results add weight to concerns about unintended consequences of pay-for-performance programs leading

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46504/psn-pdf
    February 22, 2018 - how-guiding-coalitions-promote-positive-culture-change-hospitals-longitudinal-mixed-methods https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44823/psn-pdf
    February 15, 2017 - Half were coded as "general unintentional," which includes exploratory exposures and other scenarios leading

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43664/psn-pdf
    September 01, 2016 - Inappropriate alarm settings, electrode failure leading to poor signal quality, and alerts for non-actionable

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45681/psn-pdf
    January 25, 2017 - investigators concluded that hospital spending on CLABSI and CRBSI prevention efforts is worthwhile, leading

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39662/psn-pdf
    April 30, 2014 - autopsy studies indicates that thousands of patients die every year due to missed or delayed diagnoses, leading

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46864/psn-pdf
    August 17, 2018 - However, alerts are pervasive and often irrelevant, leading patient safety experts to question whether
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