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psnet.ahrq.gov/issue/considering-insulin-pens-routine-hospital-use-consider
May 03, 2023 - May 5, 2018
Misprogramming PCA concentration leads to dosing errors.
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psnet.ahrq.gov/issue/voices-frontlines-health-care-safety
May 03, 2023 - June 24, 2020
COVID-19 leads to increased need for dialysis machines.
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psnet.ahrq.gov/issue/practitioners-agree-medication-reconciliation-value-frustration-and-difficulties-abound
August 09, 2023 - June 26, 2013
Leaving a discontinued FentaNYL infusion attached to the patient leads
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psnet.ahrq.gov/issue/improving-patient-safety-laboratory-medicine
November 16, 2022 - May 21, 2014
When diagnostic testing leads to harm: a new outcomes-based approach for
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psnet.ahrq.gov/issue/preventing-medication-errors-during-codes
February 22, 2023 - May 7, 2018
Misprogramming PCA concentration leads to dosing errors.
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psnet.ahrq.gov/issue/iv-vincristine-survey-shows-safety-improvements-needed
March 14, 2023 - June 10, 2018
Failed check system for chemotherapy leads to pharmacist's "no contest"
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digital.ahrq.gov/2020-year-review/research-summary/what-we-fund
January 01, 2020 - Research Program’s funding opportunities are designed to fund research that fills knowledge gaps and leads
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psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
January 13, 2021 - nonsevere penicillin allergy, treatment with cephalosporins without preceding penicillin skin testing leads … Use of non–beta-lactam alternatives in patients reporting penicillin allergies leads to more treatment … National Penicillin Allergy Day (September 28).( 16 )
Take-Home Points
Unverified penicillin allergy leads … January 1, 2019
WebM&M Cases
Lapse in Antibiotics Leads
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psnet.ahrq.gov/node/41027/psn-pdf
September 01, 2016 - This problem leads to alert fatigue on the part of clinicians, but thus far, system
developers have
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psnet.ahrq.gov/node/45751/psn-pdf
January 01, 2019 - The authors suggest that promoting patient safety leads to improved financial outcomes; however, it
-
psnet.ahrq.gov/node/45744/psn-pdf
December 19, 2017 - They concluded that hospital size leads to bias when evaluating
hospital performance, disproportionately
-
psnet.ahrq.gov/node/47372/psn-pdf
January 01, 2019 - issue/medical-office-survey-patient-safety-culture
https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
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psnet.ahrq.gov/node/45279/psn-pdf
September 27, 2016 - Although some
studies have suggested that more clinical supervision leads to fewer adverse events, there
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psnet.ahrq.gov/issue/management-operating-room-critical-events
March 27, 2024 - WebM&M Cases
Uterine Artery Injury during Cesarean Delivery Leads
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psnet.ahrq.gov/issue/your-attention-please-designing-effective-warnings
March 14, 2023 - May 7, 2018
Misprogramming PCA concentration leads to dosing errors.
-
psnet.ahrq.gov/issue/latest-heparin-fatality-speaks-loudly-what-have-you-done-stop-bleeding
May 03, 2023 - June 10, 2018
Electronic prescribing vulnerabilities: height and weight mix-up leads
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psnet.ahrq.gov/issue/shared-mdis-can-cross-contamination-be-avoided
May 03, 2023 - May 3, 2023
Failed check system for chemotherapy leads to pharmacist's "no contest" plea
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psnet.ahrq.gov/issue/technology-education-and-safety
December 15, 2021 - September 21, 2022
WebM&M Cases
Saline Flush Leads to
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digital.ahrq.gov/program-overview/research-stories/supporting-health-systems-advancing-care-delivery
January 01, 2023 - Exchange Facilitating data exchange between public health and clinical care information systems leads
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psnet.ahrq.gov/issue/nutrition-support-safety
July 10, 2024 - Cases
Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads