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psnet.ahrq.gov/issue/criminalization-human-error-and-guilty-verdict-travesty-justice-threatens-patient-safety
September 07, 2022 - May 2, 2018
Failed check system for chemotherapy leads to pharmacist's "no contest" plea
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psnet.ahrq.gov/issue/three-new-best-practices-2022-2023-targeted-medication-safety-best-practices-hospitals
March 15, 2022 - November 2, 2022
Leaving a discontinued FentaNYL infusion attached to the patient leads
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psnet.ahrq.gov/issue/quality-and-safety-1
September 21, 2022 - February 3, 2021
When medical care leads to harm—difficulty finding words: a teachable
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psnet.ahrq.gov/issue/premature-closure-not-so-fast
September 28, 2022 - March 2, 2022
WebM&M Cases
"Superficial" Report Leads
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psnet.ahrq.gov/issue/independent-double-checks-worth-effort-if-used-judiciously-and-properly
January 23, 2019 - Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared
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psnet.ahrq.gov/issue/implementing-optimal-team-based-care-reduce-clinician-burnout
January 16, 2019 - April 28, 2021
Unprofessional Behavior Leads to Complications.
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psnet.ahrq.gov/issue/safety-anesthetic-and-perioperative-medication-practices
January 14, 2019 - May 4, 2022
WebM&M Cases
Saline Flush Leads to Acute
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psnet.ahrq.gov/issue/near-miss-audit-obstetrics
March 06, 2024 - April 1, 2021
WebM&M Cases
Lack of Sepsis Recognition Leads
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psnet.ahrq.gov/issue/redesigning-morbidity-and-mortality-program-university-affiliated-pediatric-anesthesia
March 27, 2024 - July 16, 2014
An anesthesiology department leads culture change at a hospital system
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - This state of low solute and high free water intake leads to hypotonic hyponatremia resulting in suppression … In patients in this state, administering solute via either isotonic or hypertonic saline leads to rapid … Related Resources
WebM&M Cases
Medication Mix-Up Leads
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psnet.ahrq.gov/issue/governor-signs-executive-order-creating-new-division-patient-safety
October 25, 2023 - Computerized Provider Order Entry
September 7, 2019
When a vital sign leads
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psnet.ahrq.gov/node/49748/psn-pdf
December 01, 2015 - However, controlled clinical studies have shown that spironolactone is far superior—its
use leads to … Many of these patients have elevated circulating
aldosterone concentrations, which leads to avid salt … The vasodilatation that occurs in the splanchnic
bed leads to a lowering of mean arterial pressure and
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psnet.ahrq.gov/node/49704/psn-pdf
March 01, 2014 - Anything
that leads to decreased stooling will tend to increase this enterohepatic circulation; most … This leads to unnecessary separation of mother
and infant and extra costs. … This typically leads to a gradually worsening anemia, rather than a stable hemoglobin for 10 days followed
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psnet.ahrq.gov/issue/safety-investigations-across-pond-deep-learning-englands-healthcare-safety-investigation
May 03, 2023 - August 3, 2022
Incorrect use of smart infusion pump in the operating room (OR) leads
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psnet.ahrq.gov/primer/falls
October 27, 2021 - members, and health care staff, and may mark the beginning of a negative cycle where fear of falling leads … 13, 2022
View More
Related WebM&M
Failure to Ensure Patient Safety Leads
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psnet.ahrq.gov/issue/best-practices-safe-medication-administration-during-anesthesia-care
July 05, 2016 - September 30, 2020
Incorrect use of smart infusion pump in the operating room (OR) leads
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psnet.ahrq.gov/issue/dtap-tdap-mix-ups-now-affecting-hundreds-patients
June 10, 2018 - September 22, 2010
Electronic prescribing vulnerabilities: height and weight mix-up leads
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psnet.ahrq.gov/issue/patient-safety-surgery-0
October 18, 2017 - Summary
July 23, 2024
WebM&M Cases
Saline Flush Leads
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psnet.ahrq.gov/issue/how-has-current-economy-affected-patient-safety
May 07, 2018 - May 7, 2018
Failed check system for chemotherapy leads to pharmacist's "no contest" plea
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psnet.ahrq.gov/issue/sick-children-face-potentially-deadly-danger-medication-errors
September 02, 2009 - May 19, 2018
Failed check system for chemotherapy leads to pharmacist's "no contest"