-
psnet.ahrq.gov/issue/dtap-tdap-mix-ups-now-affecting-hundreds-patients
June 10, 2018 - June 10, 2018
Electronic prescribing vulnerabilities: height and weight mix-up leads
-
psnet.ahrq.gov/issue/hospital-safety-records-ceo-pay-increasingly-linked
March 03, 2010 - November 23, 2016
Parkland knee surgery done by doctor in training leads to amputation
-
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
-
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/discharge-missteps-can-send-seniors-back-hospital
March 28, 2012 - March 7, 2012
Parkland knee surgery done by doctor in training leads to amputation, questions
-
psnet.ahrq.gov/issue/ongoing-preventable-fatal-events-fentanyl-transdermal-patches-are-alarming
May 07, 2018 - April 29, 2018
Misprogramming PCA concentration leads to dosing errors.
-
psnet.ahrq.gov/issue/new-technologies-radiation-therapy-ensuring-patient-safety-radiation-safety-and-regulatory
November 01, 2023 - 2023
WebM&M Cases
Inadvertent Use of More Potent Acid Leads
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psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
July 02, 2011 - This process leads to arrythmias including ST and T wave changes, neurogenic pulmonary edema, hypertension … December 14, 2022
WebM&M Cases
Saline Flush Leads … Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads
-
psnet.ahrq.gov/node/49833/psn-pdf
June 01, 2018 - Studies have
demonstrated that earlier treatment with thrombolytics leads to better functional outcomes … neck
and head could have excluded a basilar artery thrombosis, one of the few ischemic strokes that leads … on reducing underdiagnosis of stroke, overdiagnosis can also
be problematic, particularly when it leads
-
psnet.ahrq.gov/issue/when-health-care-moves-online-many-patients-are-left-behind
August 19, 2020 - June 17, 2020
Fear of Covid-19 leads other patients to decline critical treatment.
-
psnet.ahrq.gov/issue/ebola-us-patient-zero-lessons-misdiagnosis-and-effective-use-electronic-health-records
June 21, 2023 - May 22, 2019
WebM&M Cases
Lapse in Antibiotics Leads
-
psnet.ahrq.gov/issue/inpatients-notes-sensemaking-fostering-shared-understanding-clinical-teams
November 25, 2020 - November 1, 2023
View More
Related Resources
Unprofessional Behavior Leads
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psnet.ahrq.gov/issue/during-pandemic-aspire-identify-and-prevent-medication-errors-and-avoid-blaming-attitudes
September 07, 2022 - December 16, 2020
Incorrect use of smart infusion pump in the operating room (OR) leads
-
psnet.ahrq.gov/issue/diagnostic-error-internal-medicine
May 25, 2022 - April 3, 2018
When diagnostic testing leads to harm: a new outcomes-based approach for
-
psnet.ahrq.gov/issue/im-smiling-under-here-masks-plexiglass-and-questions-norm-hospitals-lure-patients-back-covid
June 24, 2020 - June 17, 2020
Fear of Covid-19 leads other patients to decline critical treatment.
-
psnet.ahrq.gov/issue/utilizing-quality-improvement-methods-prevent-falls-and-injury-falls-enhancing-resident
September 01, 2021 - Resources
WebM&M Cases
Failure to Ensure Patient Safety Leads
-
psnet.ahrq.gov/issue/what-interventions-could-reduce-diagnostic-error-emergency-departments-review-evidence
November 25, 2020 - April 3, 2018
When diagnostic testing leads to harm: a new outcomes-based approach for
-
psnet.ahrq.gov/issue/drug-induced-hypoglycaemia-new-insight-old-problem
October 19, 2022 - Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared
-
psnet.ahrq.gov/issue/computerized-physician-order-entry-injectable-antineoplastic-drugs-epidemiologic-study
October 19, 2022 - May 11, 2019
Electronic prescribing vulnerabilities: height and weight mix-up leads to
-
psnet.ahrq.gov/issue/differences-between-human-error-risk-behavior-and-reckless-behavior-are-key-just-culture
September 23, 2020 - December 16, 2020
Incorrect use of smart infusion pump in the operating room (OR) leads