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  1. 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
  2. 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
  3. 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
  4. psnet.ahrq.gov/issue/premature-closure-not-so-fast
    September 28, 2022 - March 2, 2022 WebM&M Cases "Superficial" Report Leads
  5. 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
  6. psnet.ahrq.gov/issue/implementing-optimal-team-based-care-reduce-clinician-burnout
    January 16, 2019 - April 28, 2021 Unprofessional Behavior Leads to Complications.
  7. psnet.ahrq.gov/issue/safety-anesthetic-and-perioperative-medication-practices
    January 14, 2019 - May 4, 2022 WebM&M Cases Saline Flush Leads to Acute
  8. psnet.ahrq.gov/issue/near-miss-audit-obstetrics
    March 06, 2024 - April 1, 2021 WebM&M Cases Lack of Sepsis Recognition Leads
  9. 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
  10. 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
  11. 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
  12. Psn-Pdf (pdf file)

    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
  13. Psn-Pdf (pdf file)

    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
  14. 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
  15. 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
  16. 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
  17. 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
  18. psnet.ahrq.gov/issue/patient-safety-surgery-0
    October 18, 2017 - Summary July 23, 2024 WebM&M Cases Saline Flush Leads
  19. 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
  20. 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"

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