-
psnet.ahrq.gov/issue/maximizing-smart-pump-technology-enhance-patient-safety
April 25, 2018 - May 5, 2018
Misprogramming PCA concentration leads to dosing errors.
-
psnet.ahrq.gov/issue/taking-closer-look-medication-errors-involve-oxytocin
July 18, 2018 - June 10, 2018
Misprogramming PCA concentration leads to dosing errors.
-
psnet.ahrq.gov/issue/preventing-patient-positioning-injuries-nonoperating-room-setting
November 21, 2012 - June 15, 2022
WebM&M Cases
Saline Flush Leads to Acute
-
psnet.ahrq.gov/issue/negotiating-medical-virtues-toward-development-physician-mistake-disclosure-model
June 14, 2017 - June 14, 2011
A medical error leads to tragedy: how do we inform the patient?
-
psnet.ahrq.gov/issue/complementary-telephone-strategies-improve-postdischarge-communication
July 02, 2014 - Cases
Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads
-
psnet.ahrq.gov/issue/smarter-clinical-checklists-how-minimize-checklist-fatigue-and-maximize-clinician-performance
July 10, 2017 - Radiology Reads in the Digital Era
January 1, 2017
An anesthesiology department leads
-
psnet.ahrq.gov/issue/ismp-national-vaccine-errors-reporting-program-one-three-vaccine-errors-associated-age
July 27, 2016 - Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared
-
psnet.ahrq.gov/issue/chemotherapy-dose-limits-set-users-computer-order-entry-system
August 13, 2008 - May 11, 2019
Electronic prescribing vulnerabilities: height and weight mix-up leads to
-
psnet.ahrq.gov/issue/patient-safety-it-just-another-bandwagon
June 12, 2013 - July 30, 2014
When diagnostic testing leads to harm: a new outcomes-based approach for
-
psnet.ahrq.gov/issue/improved-prophylaxis-and-decreased-rates-preventable-harm-use-mandatory-computerized-clinical
June 21, 2016 - February 19, 2014
Error in body weight estimation leads to inadequate parenteral anticoagulation
-
psnet.ahrq.gov/issue/perspective-road-map-academic-departments-promote-scholarship-quality-improvement-and-patient
July 02, 2014 - March 30, 2011
An anesthesiology department leads culture change at a hospital system
-
psnet.ahrq.gov/issue/achieving-high-reliability-organization-through-implementation-arcc-model-systemwide
March 21, 2018 - April 4, 2011
An anesthesiology department leads culture change at a hospital system
-
psnet.ahrq.gov/issue/covid-19-delaying-routine-care-chronic-disease-startups-brace-slew-complications
May 02, 2018 - June 24, 2020
Fear of Covid-19 leads other patients to decline critical treatment.
-
psnet.ahrq.gov/issue/normalization-deviance-do-we-unknowingly-accept-doing-wrong-thing
May 23, 2018 - March 27, 2024
Leaving a discontinued FentaNYL infusion attached to the patient leads
-
psnet.ahrq.gov/issue/no-fault-compensation-medical-injuries-prospect-error-prevention
May 20, 2015 - February 17, 2011
A medical error leads to tragedy: how do we inform the patient?
-
psnet.ahrq.gov/issue/effectiveness-toyota-process-redesign-reducing-thyroid-gland-fine-needle-aspiration-error
June 14, 2011 - January 15, 2014
When diagnostic testing leads to harm: a new outcomes-based approach
-
psnet.ahrq.gov/issue/perioperative-medication-errors-uncovering-risk-behind-drapes
March 27, 2018 - April 5, 2023
WebM&M Cases
Saline Flush Leads to Acute
-
psnet.ahrq.gov/issue/development-patient-safety-program-across-continuum-care
September 21, 2009 - Cases
Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads
-
psnet.ahrq.gov/issue/disclosure-medical-errors-right-thing-do
September 13, 2010 - November 30, 2016
A medical error leads to tragedy: how do we inform the patient?
-
psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation-25-pioneering-success-safety-25th-anniversary-provokes
January 01, 2015 - January 13, 2013
An anesthesiology department leads culture change at a hospital system