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psnet.ahrq.gov/issue/shared-mdis-can-cross-contamination-be-avoided
May 03, 2023 - May 3, 2023
Failed check system for chemotherapy leads to pharmacist's "no contest" plea
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psnet.ahrq.gov/issue/technology-education-and-safety
December 15, 2021 - September 21, 2022
WebM&M Cases
Saline Flush Leads to
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - 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 … 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/issue/nutrition-support-safety
July 10, 2024 - Cases
Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads
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psnet.ahrq.gov/issue/improving-hospital-performance-culture-change-not-answer
September 27, 2016 - They argue that better people management leads to, rather than results from, an improved organizational
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psnet.ahrq.gov/issue/medical-mistakes-scare-public-school-parents
November 04, 2015 - April 30, 2014
Mother says ER misdiagnosis leads to son's death.
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psnet.ahrq.gov/issue/fda-blame-drug-shortages
April 11, 2012 - May 7, 2014
Mother says ER misdiagnosis leads to son's death.
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psnet.ahrq.gov/issue/sponges-tools-and-more-left-inside-washington-hospital-patients
October 30, 2013 - October 30, 2013
WebM&M Cases
Sleep Deprivation Leads
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psnet.ahrq.gov/issue/safeguarding-storage-drug-products
December 15, 2010 - May 7, 2018
Misprogramming PCA concentration leads to dosing errors.
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psnet.ahrq.gov/issue/doctors-age-worries-about-their-ability-grow
December 23, 2012 - November 4, 2020
Fear of Covid-19 leads other patients to decline critical treatment.
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psnet.ahrq.gov/issue/best-medicine-fixing-modern-hospital
February 06, 2008 - February 6, 2008
WebM&M Cases
Lapse in Antibiotics Leads
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psnet.ahrq.gov/issue/look-alike-sound-alike-drugs-trigger-dangers
June 29, 2016 - May 7, 2018
Misprogramming PCA concentration leads to dosing errors.
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psnet.ahrq.gov/issue/not-what-doctor-ordered
November 23, 2016 - November 4, 2015
Parkland knee surgery done by doctor in training leads to amputation
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psnet.ahrq.gov/issue/effects-electrode-misplacement-clinicians-interpretation-standard-12-lead-electrocardiogram
February 10, 2016 - Misplacement of the electrical leads when performing a standard 12-lead electrocardiogram (ECG) significantly
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psnet.ahrq.gov/issue/assessing-impact-teaching-patient-safety-principles-medical-students-during-surgical
November 27, 2012 - found that teaching medical students practical applications of previously taught safety principles leads
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psnet.ahrq.gov/issue/important-actions-community-pharmacists-need-take-now-reduce-potentially-harmful-dispensing
June 30, 2021 - May 7, 2018
Electronic prescribing vulnerabilities: height and weight mix-up leads to
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psnet.ahrq.gov/issue/cms-30-minute-rule-drug-administration-needs-revision
October 21, 2021 - June 10, 2018
Electronic prescribing vulnerabilities: height and weight mix-up leads
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psnet.ahrq.gov/issue/black-or-other-doctors-may-be-relying-race-make-decisions-about-your-health
September 15, 2021 - August 19, 2020
Fear of Covid-19 leads other patients to decline critical treatment.
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psnet.ahrq.gov/issue/ismp-guidelines-safe-medication-use-perioperative-and-procedural-settings
November 16, 2022 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads
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psnet.ahrq.gov/issue/recognizing-unsafe-care-what-it-and-how-report-it
April 22, 2020 - September 8, 2021
Electronic prescribing vulnerabilities: height and weight mix-up leads