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Showing results for "leads".

  1. 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
  2. psnet.ahrq.gov/issue/anesthesia-patient-safety-podcast
    September 04, 2024 - March 27, 2024 WebM&M Cases Saline Flush Leads to Acute
  3. Psn-Pdf (pdf file)

    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
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45744/psn-pdf
    December 19, 2017 - They concluded that hospital size leads to bias when evaluating hospital performance, disproportionately
  5. Psn-Pdf (pdf file)

    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
  6. Psn-Pdf (pdf file)

    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
  7. 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
  8. psnet.ahrq.gov/issue/voices-frontlines-health-care-safety
    May 03, 2023 - June 24, 2020 COVID-19 leads to increased need for dialysis machines.
  9. Psn-Pdf (pdf file)

    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
  10. 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.
  11. Psn-Pdf (pdf file)

    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
  12. psnet.ahrq.gov/issue/preventing-medication-errors-during-codes
    February 22, 2023 - May 7, 2018 Misprogramming PCA concentration leads to dosing errors.
  13. 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
  14. Psn-Pdf (pdf file)

    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
  15. psnet.ahrq.gov/issue/management-operating-room-critical-events
    March 27, 2024 - WebM&M Cases Uterine Artery Injury during Cesarean Delivery Leads
  16. 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
  17. 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
  18. psnet.ahrq.gov/issue/safemedicationuseca
    October 10, 2012 - September 9, 2015 Selection of incorrect medication pump leads to chemotherapy overdose
  19. 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
  20. 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

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