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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. … Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016. … https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant … handoffs and transitions, and the benefits and risks
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
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psnet.ahrq.gov/issue/20-meq-potassium-chloride-5-dextrose-and-045-sodium-chloride-injection
August 12, 2015 - January 10, 2007
Misprogramming PCA concentration leads to dosing errors.
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psnet.ahrq.gov/node/44689/psn-pdf
February 24, 2018 - The authors argue apportioning responsibility between systems and the
individuals within them leads
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psnet.ahrq.gov/node/47991/psn-pdf
July 12, 2019 - disclosure-hospital-adverse-events-and-its-association-patients-ratings-quality-care
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
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psnet.ahrq.gov/node/73258/psn-pdf
May 12, 2021 - rate-sepsis-hospitalizations-after-misdiagnosis-adult-emergency-department-patients-look
https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
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psnet.ahrq.gov/node/47372/psn-pdf
January 01, 2019 - issue/medical-office-survey-patient-safety-culture
https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
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psnet.ahrq.gov/node/47812/psn-pdf
April 17, 2019 - https://psnet.ahrq.gov/issue/overtreatment-united-states
https://psnet.ahrq.gov/issue/when-medical-care-leads-harm-difficulty-finding-words-teachable-moment
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psnet.ahrq.gov/node/45751/psn-pdf
January 01, 2019 - The authors suggest that promoting patient safety leads to improved financial outcomes; however, it
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psnet.ahrq.gov/node/45091/psn-pdf
February 14, 2017 - critical care
interprofessional teams found that clinicians' emotional exhaustion affects teamwork, which leads
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psnet.ahrq.gov/node/45907/psn-pdf
December 22, 2017 - primary-care-collaboration-improve-diagnosis-and-screening-colorectal-cancer
Delayed diagnosis of colon cancer due to missed screening or follow-up leads
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psnet.ahrq.gov/node/45392/psn-pdf
August 17, 2016 - However, if accuracy levels vary across providers, pooling
independent judgment leads to worse diagnostic
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads … Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads … Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads … Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads … March 1, 2023
WebM&M Cases
Lack of Sepsis Recognition Leads
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psnet.ahrq.gov/node/865429/psn-pdf
April 24, 2024 - (VF) may be
induced by attempted cardioversion.8 It is therefore very important to connect the ECG leads … This
may take place in the electrophysiology lab or in the operating room where pacing via epicardial leads … team forgetting to check that the cardioverter/defibrillator had been
hooked up correctly to the ECG leads … shown to prolong life by reducing rates of myocardial infarction.20
Connect defibrillators to the ECG leads … With this set-up, a separate pair of chest leads directly connected to the defibrillator is no
longer
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psnet.ahrq.gov/node/41325/psn-pdf
October 06, 2016 - Missing equipment or
information leads to interruptions in performing tasks, which have been linked
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psnet.ahrq.gov/node/35434/psn-pdf
June 14, 2011 - translocation of root cause analysis (RCA) techniques from non-health care
settings and how this method leads
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psnet.ahrq.gov/node/46985/psn-pdf
July 02, 2019 - treatment-challenges-after-discharge
https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
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psnet.ahrq.gov/issue/second-opinion-consult-computer
June 03, 2020 - Copy Citation
Related Resources From the Same Author(s)
Fear of Covid-19 leads
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psnet.ahrq.gov/node/43788/psn-pdf
February 25, 2015 - Staff responses suggested that insufficient time to manage their workload leads to safety problems,
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psnet.ahrq.gov/node/46411/psn-pdf
April 12, 2019 - effect-health-information-exchange-recognition-medication-discrepancies-
interrupted-when-data
Inaccurate medication reconciliation leads
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psnet.ahrq.gov/issue/lack-standard-dosing-methods-contributes-iv-errors
December 02, 2020 - May 5, 2018
Failed check system for chemotherapy leads to pharmacist's "no contest" plea