-
psnet.ahrq.gov/issue/accidental-overdoses-involving-fluorouracil-infusions
July 08, 2015 - June 10, 2018
Selection of incorrect medication pump leads to chemotherapy overdose.
-
psnet.ahrq.gov/issue/i-cant-turn-my-brain
December 14, 2016 - December 14, 2016
Fear of Covid-19 leads other patients to decline critical treatment
-
psnet.ahrq.gov/issue/thats-way-we-do-things-around-here
June 10, 2018 - October 26, 2011
An anesthesiology department leads culture change at a hospital system
-
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"
-
psnet.ahrq.gov/issue/building-case-medication-reconciliation
June 10, 2018 - May 7, 2018
The absence of a drug–disease interaction alert leads to a child's death.
-
psnet.ahrq.gov/issue/inattentional-blindness-what-captures-your-attention
May 07, 2018 - June 30, 2021
Electronic prescribing vulnerabilities: height and weight mix-up leads
-
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
-
psnet.ahrq.gov/issue/people-disabilities-fear-pandemic-will-worsen-medical-biases
April 27, 2016 - April 17, 2019
COVID-19 leads to increased need for dialysis machines.
-
psnet.ahrq.gov/issue/most-crucial-half-hour-hospital-shift-change
August 17, 2016 - Cases
Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads
-
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
-
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
-
digital.ahrq.gov/2019-year-review/research-summary/overview
January 01, 2019 - Research Program’s funding opportunities are designed to fund research that fills knowledge gaps and leads
-
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.
-
digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/aas-ih-2002
January 01, 2002 - "Teledermatology leads to some change in the performance of tasks for primary care and the dermatology
-
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
-
effectivehealthcare.ahrq.gov/sites/default/files/dementia-horizon-scan-high-impact-1506.pdf
June 01, 2015 - AHRQ did not directly
participate in horizon scanning, assessing the leads for topics, or providing … Since that implementation, review of more than 21,000 leads about potential topics has resulted in
identification … Besides tracking topics formally, the leads for potential topics identified by the system’s staff of
-
effectivehealthcare.ahrq.gov/sites/default/files/06_devdelays_autism_potential_high_impact_june_2012.pdf
January 01, 2012 - AHRQ did not directly
participate in horizon scanning, assessing the leads for topics, or providing … Since that implementation, more than 11,000 leads about topics have resulted in identification and … Discussion
This priority area has a paucity of leads and innovations, despite intensive scanning for