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psnet.ahrq.gov/issue/patient-safety-or-0
October 23, 2024 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads
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psnet.ahrq.gov/issue/anesthesia-patient-safety-podcast
September 04, 2024 - March 27, 2024
WebM&M Cases
Saline Flush Leads to Acute
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psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - Mismatch of patient identifiers or failure to label the tube leads to test
cancellation and caregiver … Examples of Patient Harm Associated with Laboratory Errors
Error identifying an organism leads to incorrect … Data entry error of a troponin result leads to false diagnosis of myocardial infarction and
unnecessary … Mislabeled blood gas specimen leads to delay in results and mismanagement of a patient who is
coding … Miscommunication of a high INR result leads to near fatal bleeding in an outpatient who has
received
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psnet.ahrq.gov/node/45744/psn-pdf
December 19, 2017 - They concluded that hospital size leads to bias when evaluating
hospital performance, disproportionately
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psnet.ahrq.gov/node/41027/psn-pdf
September 01, 2016 - This problem leads to alert fatigue on the part of clinicians, but thus far, system
developers have
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psnet.ahrq.gov/node/45279/psn-pdf
September 27, 2016 - Although some
studies have suggested that more clinical supervision leads to fewer adverse events, there
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psnet.ahrq.gov/issue/practitioners-agree-medication-reconciliation-value-frustration-and-difficulties-abound
August 09, 2023 - March 11, 2020
Leaving a discontinued FentaNYL infusion attached to the patient leads
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psnet.ahrq.gov/issue/voices-frontlines-health-care-safety
May 03, 2023 - June 24, 2020
COVID-19 leads to increased need for dialysis machines.
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psnet.ahrq.gov/node/857259/psn-pdf
November 30, 2023 - Medication Mix-Up Leads to Patient Death
November 30, 2023
Sanchez L, Romano PS. … Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023. … https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
The Case
An 81-year-old man was transferred … medication errors can occur despite obvious “red flags” at the
https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
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psnet.ahrq.gov/curated-library/rapid-response-systems
September 07, 2019 - Read More
Lack of Sepsis Recognition Leads to Delay in Care Following … Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.
By Gary S.
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psnet.ahrq.gov/node/33568/psn-pdf
September 07, 2019 - than
https://psnet.ahrq.gov/web-mm/failure-report
https://psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia … hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
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psnet.ahrq.gov/issue/preventing-medication-errors-during-codes
February 22, 2023 - May 7, 2018
Misprogramming PCA concentration leads to dosing errors.
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psnet.ahrq.gov/issue/improving-patient-safety-laboratory-medicine
November 16, 2022 - May 21, 2014
When diagnostic testing leads to harm: a new outcomes-based approach for
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psnet.ahrq.gov/node/838197/psn-pdf
September 28, 2022 - Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without … Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without … /psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-
discharge-leads-picc … ://psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc … ://psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
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psnet.ahrq.gov/issue/management-operating-room-critical-events
March 27, 2024 - WebM&M Cases
Uterine Artery Injury during Cesarean Delivery Leads
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psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
January 29, 2021 - Disconnecting the ETT from the circuit leads to a transient loss of PEEP but makes it less likely for … WebM&M Cases
An Incomplete Anesthesia History Leads … WebM&M Cases
Uterine Artery Injury during Cesarean Delivery Leads … August 31, 2022
WebM&M Cases
Saline Flush Leads
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psnet.ahrq.gov/issue/work-systems-analysis-approach-understanding-fatigue-hospital-nurses
July 08, 2020 - They conclude that a work systems approach leads to a better understanding of occupational fatigue and
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psnet.ahrq.gov/issue/safemedicationuseca
October 10, 2012 - September 9, 2015
Selection of incorrect medication pump leads to chemotherapy overdose
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psnet.ahrq.gov/issue/australian-commission-safety-and-quality-health-care
January 27, 2015 - Established in January 2006, the Commission leads and coordinates improvements in safety and quality
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psnet.ahrq.gov/issue/latest-heparin-fatality-speaks-loudly-what-have-you-done-stop-bleeding
May 03, 2023 - June 10, 2018
Electronic prescribing vulnerabilities: height and weight mix-up leads