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Medication error in the care of HIV/AIDS patients: electronic surveillance, confirmation, and adverse events. | PSNet

psnet.ahrq.gov/issue/medication-error-care-hivaids-patients-electronic-surveillance-confirmation-and-adverse

September 28, 2022 - December 4, 2016 The need for closed-loop systems for management of abnormal test results … July 2, 2019 Understanding test results follow-up in the ambulatory setting: analysis … September 30, 2020 Pharmacist linkage in care transitions: from academic medical … June 28, 2010 The influence of the structure and culture of medical group practices on

Project BOOST Increases Patient Understanding of Treatment and Follow-up Care | PSNet

psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care

February 26, 2025 - Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test … Based on the success of this test, Patient Safe-D was incorporated as part of the Society of Hospital … present at follow-up appointments with their primary care providers. 6 Many patients are discharged with test … Patient safety concerns arising from test results that return after hospital discharge. … Tying up loose ends: discharging patients with unresolved medical issues.

Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention | PSNet

psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention

May 01, 2011 - by a negative cerebrospinal spinal fluid (CSF) fluorescent treponemal antibody absorption (FTA-ABS) test … Additional blood tests were sent out to test for other infectious causes of her symptoms, and the patient … The penicillin sensitivity test result was negative, so the allergist placed orders to initiate penicillin … Most serious medical errors are due to miscommunication between medical providers during transitions … WebM&M Cases Out of Sight, Out of Mind: Out-of-Office Test

Patient safety trends in 2022: an analysis of 256,679 serious events and incidents from the nation’s largest event reporting database. | PSNet

psnet.ahrq.gov/issue/patient-safety-trends-2022-analysis-256679-serious-events-and-incidents-nations-largest-event

July 24, 2024 - The most frequently reported event continues to be Error Related to Procedure/Treatment/Test followed … by Complication of Procedure/Treatment/Test, Medication Error, and Fall. … August 23, 2023 Medical errors kill thousands of people each year.

Radiographers' experience of preventing patient safety incidents in the context of radiological examinations. | PSNet

psnet.ahrq.gov/issue/radiographers-experience-preventing-patient-safety-incidents-context-radiological

December 20, 2017 - October 19, 2022 Target-focused medical emergency team training using a human patient … Preanalytical errors in primary healthcare: a questionnaire study of information search procedures, test … request management and test tube labelling. … February 18, 2009 Is the test result correct? … October 18, 2023 Perceptions of radiation safety culture in medical imaging by role.

From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case | PSNet

psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case

October 02, 2013 - Misdiagnoses are most often linked to bedside defects in history, physical exam, test ordering, or test … Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377-384. … The new era of medical imaging—progress and pitfalls. N Engl J Med. 2006;354:2822-2828. … Reprinted from ( 1 ) with permission from the American Medical Association. … October 2, 2013 The role for policy in AI-assisted medical diagnosis.

Medical mystery: alcoholism didn’t cause man’s diabetes and cirrhosis. | PSNet

psnet.ahrq.gov/issue/medical-mystery-alcoholism-didnt-cause-mans-diabetes-and-cirrhosis

July 06, 2011 - Newspaper/Magazine Article Medical mystery: alcoholism didn’t cause man’s diabetes … June 22, 2011 Five simple steps to avoid becoming a medical mystery. … December 20, 2017 Electronic medicine can send you test results quickly. … December 5, 2018 Check your medical records for dangerous errors. … July 27, 2011 Medical misdiagnoses can have fatal consequences.

Temporal clustering of critical illness events on medical wards. | PSNet

psnet.ahrq.gov/issue/temporal-clustering-critical-illness-events-medical-wards

January 31, 2024 - Study Temporal clustering of critical illness events on medical wards. … Temporal clustering of critical illness events on medical wards. … Temporal clustering of critical illness events on medical wards. … September 20, 2011 A systematic review of interventions to follow-up test results pending … 12, 2016 Exploratory analyses of the "failure to rescue" measure: evaluation through medical

Error-avoidance recommendations for tubing misconnections when using luer-tip connectors: a statement by the USP Safe Medication Use Expert Committee. | PSNet

psnet.ahrq.gov/issue/error-avoidance-recommendations-tubing-misconnections-when-using-luer-tip-connectors

November 21, 2018 - Resources From the Same Author(s) Impact of interactions between drugs and laboratory test … results on diagnostic test interpretation—a systematic review. … November 21, 2018 Diagnostic error as a result of drug-laboratory test interactions. … Care Providers Indwelling Tubes and Catheters Administration Errors Practice Guidelines Medical

Drug–drug interactions that should be non-interruptive in order to reduce alert fatigue in electronic health records. | PSNet

psnet.ahrq.gov/issue/drug-drug-interactions-should-be-non-interruptive-order-reduce-alert-fatigue-electronic

December 31, 2014 - David Blumenthal discusses DDI alert fatigue and other issues related to medical information technology … June 3, 2020 Impact of interactions between drugs and laboratory test results on diagnostic … test interpretation—a systematic review. … November 21, 2018 Diagnostic error as a result of drug-laboratory test interactions.

The hidden curricula of medical education: a scoping review. | PSNet

psnet.ahrq.gov/issue/hidden-curricula-medical-education-scoping-review

January 13, 2021 - Review The hidden curricula of medical education: a scoping review. … The Hidden Curricula of Medical Education: A Scoping Review. … The Hidden Curricula of Medical Education: A Scoping Review. … Stigmatizing language and the transmission of bias in the medical record. … February 24, 2011 Follow-up of outpatient test results: a survey of house-staff practices

Exploring the sociotechnical intersection of patient safety and electronic health record implementation. | PSNet

psnet.ahrq.gov/issue/exploring-sociotechnical-intersection-patient-safety-and-electronic-health-record

May 01, 2015 - 2014 Application of human factors methods to understand missed follow-up of abnormal test … November 11, 2020 Graphical display of diagnostic test results in electronic health records … January 16, 2019 How context affects electronic health record–based test result follow-up … January 7, 2015 We need to talk: an observational study of the impact of electronic medical … in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical

Development and psychometric testing of a tool to measure missed nursing care. | PSNet

psnet.ahrq.gov/issue/development-and-psychometric-testing-tool-measure-missed-nursing-care

August 20, 2018 - August 20, 2018 Impact of interactions between drugs and laboratory test results on diagnostic … test interpretation—a systematic review. … November 21, 2018 Diagnostic error as a result of drug-laboratory test interactions. … October 10, 2012 Changing experience of adverse medical events in the National Health

Patient safety room of horrors: a novel method to assess medical students and entering residents' ability to identify hazards of hospitalisation. | PSNet

psnet.ahrq.gov/issue/patient-safety-room-horrors-novel-method-assess-medical-students-and-entering-residents

August 14, 2018 - Study Patient safety room of horrors: a novel method to assess medical students and … Patient safety room of horrors: a novel method to assess medical students and entering residents' ability … This simulation study challenged medical students to identify patient safety hazards in a hospital … Performance evaluations, medical errors, and the production of gender inequality in emergency medical … June 7, 2016 Using an objective structured clinical examination to test adherence to

Exploring situational awareness in diagnostic errors in primary care. | PSNet

psnet.ahrq.gov/issue/exploring-situational-awareness-diagnostic-errors-primary-care

September 20, 2011 - Related Resources From the Same Author(s) Notification of abnormal lab test … results in an electronic medical record: do any safety concerns remain? … July 10, 2008 Timely follow-up of abnormal diagnostic imaging test results in an outpatient … setting: are electronic medical records achieving their potential? … April 4, 2011 Medical errors involving trainees: a study of closed malpractice claims

The NSTEMI Curbside Consultation | PSNet

psnet.ahrq.gov/web-mm/nstemi-curbside-consultation

August 04, 2021 - She had a positive troponin test without ischemic electrocardiographic changes. … At that time, a nuclear stress test was ordered, which showed a large perfusion defect suggestive of … collateral information that is actually irrelevant (“framing bias”), and placing undue reliance on test … less often than men, 24 perhaps due to more atypical presentations and underestimation of the pre-test … For this patient, curbside consultation likely led to an incorrect pre-test probability estimate for

Demanding Medical Excellence. Doctors and Accountability in the Information Age. | PSNet

psnet.ahrq.gov/issue/demanding-medical-excellence-doctors-and-accountability-information-age

May 13, 2020 - Book/Report Classic Demanding Medical Excellence. … Citation Text: Demanding Medical Excellence. Doctors and Accountability in the Information Age. … May 13, 2020 Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic … June 30, 2021 Family of woman who died after a medical error joins hospital's safety … October 3, 2017 Errors test openness at Beth Israel Deaconess.

Inappropriate prescriptions of direct oral anticoagulants (DOACs) in hospitalized patients: a narrative review. | PSNet

psnet.ahrq.gov/issue/inappropriate-prescriptions-direct-oral-anticoagulants-doacs-hospitalized-patients-narrative

November 21, 2018 - Resources From the Same Author(s) Impact of interactions between drugs and laboratory test … results on diagnostic test interpretation—a systematic review. … November 21, 2018 Diagnostic error as a result of drug-laboratory test interactions. … April 12, 2017 Investigating US medical students' motivation to respond to lapses in

Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest event reporting database. | PSNet

psnet.ahrq.gov/issue/patient-safety-trends-2021-analysis-288882-serious-events-and-incidents-nations-largest-event

May 19, 2021 - Similar to prior reports, Error Related to Procedure/Treatment/Test remained the most commonly reported … events, followed by Medication Error , Complication of Procedure/Treatment/Test, and Fall. … October 12, 2022 Reporting incidents involving the use of advanced medical technologies

Frequency and nature of communication and handoff failures in medical malpractice claims. | PSNet

psnet.ahrq.gov/issue/frequency-and-nature-communication-and-handoff-failures-medical-malpractice-claims

June 22, 2022 - Study Frequency and nature of communication and handoff failures in medical malpractice … Frequency and nature of communication and handoff failures in medical malpractice claims. … Frequency and nature of communication and handoff failures in medical malpractice claims. … March 1, 2023 The role of apology laws in medical malpractice. … April 8, 2019 Failure to notify reportable test results: significance in medical malpractice

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