-
psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
October 27, 2021 - pathophysiology is related to the effect of local anesthetics on blocking fast sodium (Na) channels, leading … communication between the operating room (OR) team members concerning the safe dosing of local anesthetics, leading … WebM&M Cases
Inadequate Anesthesia Preparation Leading
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - Case Objectives
Review the role of mistake-proofing to block errors from leading to adverse events … In medicine, the error is identified through inspection and corrected before leading to further harm. … Successive check, with the interventional radiologist questioning the indication and leading to consultation … Take-Home Points
Health care organizations must have systems in place to prevent inevitable errors from leading … Cancer
July 31, 2023
WebM&M Cases
Misconnection Leading
-
psnet.ahrq.gov/issue/patient-safety-cataract-surgery
September 23, 2020 - July 13, 2010
National estimates of insulin-related hypoglycemia and errors leading to
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psnet.ahrq.gov/issue/strategies-optimizing-or-drug-safety
November 30, 2022 - Order scanning systems may pull multiple pages through the scanner at the same time, leading
-
psnet.ahrq.gov/node/45036/psn-pdf
February 15, 2017 - who had an adverse event required transfer to an acute care hospital for diagnosis or
management, leading
-
psnet.ahrq.gov/node/42968/psn-pdf
February 26, 2014 - However, as with CPOE in general, increasing use of e-prescribing is leading to greater recognition of
-
psnet.ahrq.gov/node/47267/psn-pdf
September 05, 2018 - adult inpatient discharges generating anywhere from 1.02
billion to 1.07 billion medication orders and leading
-
psnet.ahrq.gov/node/44026/psn-pdf
November 03, 2015 - effect-postdischarge-virtual-ward-readmission-or-death-high-risk-patients-randomized-clinical
https://psnet.ahrq.gov/issue/new-hhs-data-shows-major-strides-made-patient-safety-leading-improved-care-and-savings
-
psnet.ahrq.gov/issue/us-inaction-lets-look-alike-tubes-kill-patients
September 01, 2008 - Medication Safety
March 31, 2022
Investigation of urology intraoperative events leading
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.37_slideshow.ppt
November 01, 2003 - clinical consequences to the patient
Poor communication among team members
Possible Factors Leading … System Failures Leading to Communication Breakdown
Differences between team members’ goals
Differences
-
psnet.ahrq.gov/node/33689/psn-pdf
October 01, 2009 - Perhaps the two biggest were those leading to the deaths of Libby
Zion in New York Hospital in 1984 … amputated
University
Community
Hospital, Tampa,
FL
1995
New focus on wrong-site surgery, ultimately
leading … dehydration
Johns Hopkins
Hospital
2001
Josie's parents form an alliance with Johns
Hopkins' leadership (leading
-
psnet.ahrq.gov/web-mm/hazards-loading-doses
December 01, 2003 - Phenytoin was listed as the fourth leading drug associated with loading dose incidents, behind only warfarin … WebM&M Cases
Failure to Adhere to Dietary Restrictions Leading … July 31, 2023
WebM&M Cases
Misconnection Leading
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psnet.ahrq.gov/web-mm/misleading-complaint
December 01, 2009 - The ED physician relied heavily on this documented triage complaint, leading to an overly focused history … This case exemplifies how multiple latent factors embedded in triage can initiate a cascade of events leading … Multiple latent factors embedded in triage can initiate a cascade of events leading to a diagnostic error
-
psnet.ahrq.gov/issue/data-docs
March 02, 2016 - March 15, 2017
Leading High-Reliability Organizations in Healthcare.
-
psnet.ahrq.gov/issue/best-medicine-fixing-modern-hospital
February 06, 2008 - March 15, 2017
Leading High-Reliability Organizations in Healthcare.
-
psnet.ahrq.gov/issue/how-business-intelligence-can-improve-patient-safety
June 27, 2018 - June 15, 2011
System issues leading to "found-on-floor" incidents: a multi-incident analysis
-
psnet.ahrq.gov/issue/failure-issue
October 20, 2015 - May 29, 2019
Leading change: why transformation efforts fail.
-
psnet.ahrq.gov/issue/robot-will-see-you-now
June 02, 2010 - April 2, 2014
Leading change: why transformation efforts fail.
-
psnet.ahrq.gov/issue/enhancing-surgical-performance-primer-non-technical-skills
January 10, 2018 - Copy Citation
Related Resources From the Same Author(s)
Leading Health Care
-
psnet.ahrq.gov/issue/patient-safety-human-factors-approach
January 01, 2019 - August 24, 2017
Leading Health Care Transformation: A Primer for Clinical Leaders.