-
psnet.ahrq.gov/node/41550/psn-pdf
March 22, 2014 - infection-unnoticed-turns-unstoppable
This newspaper article reports on gaps in communication and a missed sepsis diagnosis that led
-
psnet.ahrq.gov/node/37020/psn-pdf
July 24, 2008 - A previous
WebM&M commentary discussed a tubing error that led to administration of the wrong gas.
-
psnet.ahrq.gov/node/47646/psn-pdf
February 06, 2019 - with clinical decision support reduced certain medication errors associated with
prescribing, CPOE led
-
psnet.ahrq.gov/node/838083/psn-pdf
September 14, 2022 - In the majority of cases, the diagnostic
timeout led to the pursuit of alternative diagnoses.
-
psnet.ahrq.gov/node/47332/psn-pdf
November 02, 2018 - Clinician-facing
interventions such as development and dissemination of local guidelines also led to
-
psnet.ahrq.gov/node/846450/psn-pdf
March 22, 2023 - This analysis of 456
patients found that self-efficacy increased patient engagement in their care and led
-
psnet.ahrq.gov/node/47288/psn-pdf
December 21, 2018 - systems-thinking-and-incivility-nursing-practice-integrative-review
https://psnet.ahrq.gov/issue/creating-nurse-led-culture-minimize-horizontal-violence-acute-care-setting-multi
-
psnet.ahrq.gov/node/36915/psn-pdf
May 30, 2007 - fatal-error-sparks-debate-over-punitive-measures
This article discusses a chemotherapy overdose that led
-
psnet.ahrq.gov/node/39734/psn-pdf
November 14, 2011 - man-falls-surgical-table-st-josephs-hospital-sued
This newspaper article reports on a lawsuit regarding a safety incident that led
-
psnet.ahrq.gov/node/845305/psn-pdf
March 01, 2023 - issue/infrastructure-provide-safer-higher-quality-and-more-equitable-telehealth
The COVID-19 pandemic led
-
psnet.ahrq.gov/node/46519/psn-pdf
December 22, 2018 - reducing-iatrogenic-risks-icu-acquired-delirium-and-weakness-crossing-quality-chasm
https://psnet.ahrq.gov/issue/effect-pharmacist-led-multicomponent-intervention-focusing-medication-monitoring-phase
-
psnet.ahrq.gov/node/60842/psn-pdf
August 26, 2020 - longitudinal-medication-reconciliation-hospital-admission-discharge-and-post-discharge
https://psnet.ahrq.gov/primer/medication-reconciliation
https://psnet.ahrq.gov/issue/pharmacy-led-medication-reconciliation-programmes-hospital-transitions-systematic-review-and
-
psnet.ahrq.gov/node/72773/psn-pdf
February 24, 2021 - issue/flow-accuracy-iv-smart-pumps-outside-patient-rooms-during-covid-19
The COVID-19 pandemic has led
-
psnet.ahrq.gov/node/73891/psn-pdf
September 29, 2021 - estimated that 23% of delayed
diagnosis cases were likely to be preventable and that delayed diagnosis led
-
psnet.ahrq.gov/node/47843/psn-pdf
March 06, 2019 - The authors describe how increasing complexity and bureaucracy associated with opioid prescribing led
-
psnet.ahrq.gov/node/36801/psn-pdf
August 05, 2008 - the inconsistent use of the Department of Defense electronic medical records system
and how this has led
-
psnet.ahrq.gov/node/39132/psn-pdf
December 17, 2009 - https://psnet.ahrq.gov/issue/nurses-transforming-care
This special issue highlights the work of nurse-led
-
psnet.ahrq.gov/node/35779/psn-pdf
July 20, 2010 - https://psnet.ahrq.gov/issue/our-story
The author tells the story of medical errors that led to the
-
psnet.ahrq.gov/node/41351/psn-pdf
June 27, 2018 - This article details how miscommunication and lack of patient-centered care contributed to errors that led
-
psnet.ahrq.gov/node/40628/psn-pdf
July 20, 2011 - entire-upmc-transplant-team-missed-hepatitis-alert
This newspaper article reports how a missed test result alert led