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psnet.ahrq.gov/issue/semantically-ambiguous-language-teaching-operating-room
November 11, 2020 - March 29, 2023
WebM&M Cases
Saline Flush Leads to … Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads
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psnet.ahrq.gov/node/73875/psn-pdf
October 27, 2021 - Human Factors Champions (nurses and clinical leads who received human
factors training) observed teams … The majority of respondents felt better able to perform
as team leads, supervise their teams, provide
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psnet.ahrq.gov/node/836942/psn-pdf
April 27, 2022 - Saline Flush Leads to Acute Paralysis of an Awake
Patient: Risks of Improper Medication Labeling in … Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication
Labeling in … https://psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-
medication-labeling … The Commentary
By Robert Scott Kriss, DO
https://psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling … https://psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
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psnet.ahrq.gov/issue/proper-positioning-pharmacy-label-hospira-pca-vials-will-avoid-interference-scanning
May 05, 2018 - Related Resources From the Same Author(s)
Misprogramming PCA concentration leads … June 16, 2019
Misprogramming PCA concentration leads to dosing errors.
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psnet.ahrq.gov/issue/human-costs-training-doctors
December 17, 2014 - December 17, 2014
Parkland knee surgery done by doctor in training leads to amputation … January 14, 2011
Parkland knee surgery done by doctor in training leads to amputation
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psnet.ahrq.gov/issue/progress-preventing-name-confusion-errors
May 07, 2018 - Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared … August 8, 2018
Misprogramming PCA concentration leads to dosing errors.
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psnet.ahrq.gov/curated-library/falls-prevention-awareness-week-2024
September 07, 2019 - WebM&Ms (1)
Spotlight Case
CME/MOC
Failure to Ensure Patient Safety Leads … CME/MOC
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.
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psnet.ahrq.gov/issue/when-covid-19-hit-many-elderly-were-left-die
June 24, 2020 - November 10, 2021
When medical care leads to harm—difficulty finding words: a teachable … February 10, 2015
Fear of Covid-19 leads other patients to decline critical treatment
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psnet.ahrq.gov/node/49752/psn-pdf
January 01, 2016 - Inadvertent Use of More Potent Acid Leads to Burn
January 1, 2016
Maibach HI. … Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. 2016. … https://psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
The Case
A 31-year-old woman … https://psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
By the end of World War II
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psnet.ahrq.gov/issue/ismp-updates-its-list-drug-name-pairs-tall-man-letters
June 10, 2018 - From the Same Author(s)
Electronic prescribing vulnerabilities: height and weight mix-up leads … May 7, 2018
Misprogramming PCA concentration leads to dosing errors.
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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - VF) may be induced by attempted cardioversion. 8 It is therefore very important to connect the ECG leads … This may take place in the electrophysiology lab or in the operating room where pacing via epicardial leads … team forgetting to check that the cardioverter/defibrillator had been hooked up correctly to the ECG leads … With this set-up, a separate pair of chest leads directly connected to the defibrillator is no longer … May 16, 2022
WebM&M Cases
Saline Flush Leads to
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psnet.ahrq.gov/issue/misidentification-alphanumeric-symbols
March 26, 2014 - September 14, 2022
WebM&M Cases
Saline Flush Leads to … August 5, 2020
Incorrect use of smart infusion pump in the operating room (OR) leads
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psnet.ahrq.gov/issue/survey-lasa-drug-name-pairs-who-knows-whats-your-list-and-best-ways-prevent-mix-ups
June 10, 2018 - November 3, 2021
The absence of a drug–disease interaction alert leads to a child's death … January 23, 2019
Misprogramming PCA concentration leads to dosing errors.
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psnet.ahrq.gov/issue/misidentification-alphanumeric-symbols-both-handwritten-and-computer-generated-information
May 07, 2018 - Related Resources From the Same Author(s)
Failed check system for chemotherapy leads … June 10, 2018
Failed check system for chemotherapy leads to pharmacist's "no contest"
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psnet.ahrq.gov/node/866520/psn-pdf
August 14, 2024 - post-error slowing is not simply due to increased caution, but due to impaired cognitive
processing, and leads
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psnet.ahrq.gov/node/60903/psn-pdf
March 15, 2023 - breaking-rules-understanding-non-compliance-policies-and-guidelines
https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
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psnet.ahrq.gov/node/50373/psn-pdf
September 25, 2019 - psnet.ahrq.gov/issue/2018-update-pediatric-medical-overuse-review
https://psnet.ahrq.gov/issue/when-medical-care-leads-harm-difficulty-finding-words-teachable-moment
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psnet.ahrq.gov/issue/results-survey-pediatric-medication-safety-part-1-and-part-2
November 16, 2015 - May 5, 2018
The absence of a drug–disease interaction alert leads to a child's death. … December 2, 2015
The absence of a drug–disease interaction alert leads to a child's death
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psnet.ahrq.gov/issue/ten-years-after-iom-report-engaging-residents-quality-and-patient-safety-creating-house-staff
December 27, 2014 - December 27, 2014
An anesthesiology department leads culture change at a hospital system … March 2, 2011
An anesthesiology department leads culture change at a hospital system
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psnet.ahrq.gov/issue/role-housestaff-implementing-medication-reconciliation-admission-academic-medical-center
March 30, 2011 - March 30, 2011
An anesthesiology department leads culture change at a hospital system … March 2, 2011
An anesthesiology department leads culture change at a hospital system