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Showing results for "mistakes".

  1. Safe Medication Administration: Slide Presentation | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-slides.html
    July 01, 2023 - Although mistakes are not necessarily more common with these drugs, the consequences of errors are more

  2. Lost in the Black Hole | PSNet

    psnet.ahrq.gov/web-mm/lost-black-hole
    December 01, 2005 - Internal bleeding: the truth behind America's terrifying epidemic of medical mistakes.

  3. Double Dosing, by the Rules | PSNet

    psnet.ahrq.gov/web-mm/double-dosing-rules
    February 03, 2010 - The error occurs when individuals fall victim to the flaws within the system and mistakes are made.

  4. The Unintended Consequences of Florida Medical Liability Legislation | PSNet

    psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation
    February 01, 2003 - Without these vital conversations, there is no learning from mistakes and near misses, increasing the

  5. Patient Safety 101 | PSNet

    psnet.ahrq.gov/primer/patient-safety-101
    January 16, 2025 - Although the idea of medical mistakes has been long known, the modern literature began with a famous

  6. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital | PSNet

    psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
    May 16, 2022 - September 21, 2016 WebM&M Cases Vial Mistakes Involving

  7. Community-Based Participatory Research Slides Text Version (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/lessons-presentation.pdf
    January 01, 2013 - Content of the table: § Critical Reflective Trust: Trust, in this partnership, is at the place where mistakes

  8. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room | PSNet

    psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
    February 01, 2019 - February 1, 2019 WebM&M Cases Diagnosing Diagnostic Mistakes

  9. Glucose Roller Coaster | PSNet

    psnet.ahrq.gov/web-mm/glucose-roller-coaster
    February 02, 2022 - Internal bleeding: the truth behind America's terrifying epidemic of medical mistakes.

  10. Pocket Syringe Swap | PSNet

    psnet.ahrq.gov/web-mm/pocket-syringe-swap
    July 01, 2006 - June 14, 2019 WebM&M Cases Vial Mistakes Involving Heparin

  11. Double Dose at Transfer | PSNet

    psnet.ahrq.gov/web-mm/double-dose-transfer
    November 01, 2012 - Double Dose at Transfer Citation Text: Hackman JL. Double Dose at Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49503/psn-pdf
    February 01, 2006 - Workaround Error February 1, 2006 Pape T. Workaround Error. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/workaround-error The Case A retired 81-year-old physician with metastatic colon cancer was admitted to an acute care hospital with pneumonia and congestive heart failure (CHF). After his acute hospita…

  13. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
    October 01, 2010 - Spotlight Case July 2008 Spotlight Case October 2010 Dangerous Dialysis * * Source and Credits This presentation is based on the October 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49866/psn-pdf
    June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the Operating Room June 1, 2019 Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room The Case A 43-year-old woman was admi…

  15. Charcoal Lavage of the Lungs | PSNet

    psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
    January 01, 2016 - Charcoal Lavage of the Lungs Citation Text: Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …

  16. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Patient and Family Engagement

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/engagement.pptx
    May 01, 2017 - AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Patient and Family Engagement AHRQ Safety Program for Perinatal Care Patient and Family Engagement for Perinatal Safety AHRQ Publication No. 17-0003-6-EF May 2017 1 Learning Objectives 2 AHRQ Safety Program for Perinatal Care Patient & Fam…

  17. Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-about-cusp-slides.html
    July 01, 2023 - Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety AHRQ Safety Program for Perinatal Care Slide 1: AHRQ Safety Program for Perinatal Care Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety Slide 2: CUSP and Perinatal Safety Image: A chart is shown …

  18. Patient and Family Engagement | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cusp/modules/patient-family-engagement/sl-pat-fam.html
    September 01, 2013 - Patient and Family Engagement CUSP Toolkit The Patient and Family Engagement module of the Comprehensive Unit-based Safety Program (CUSP) Toolkit. The CUSP toolkit is a modular approach to patient safety, and modules presented in this toolkit are interconnected and are aimed at improving patient safety. Con…

  19. The Soil, Not the Seed: The Real Problem with Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
    March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis Patrice Spath, BA, RHIT, and William Minogue, MD | July 1, 2008  View more articles from the same authors. Citation Text: Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause …

  20. Action Planning for the SOPS Surveys Webcast Transcript (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/action-planning-webcast-transcript.pdf
    June 01, 2019 - Gray, Slide 13 All right, “one of the biggest mistakes you can make is to administer a company-wide … insight into reasons that that past efforts have failed and it could help you actually avoid similar mistakes … Nonpunitive Response to Error is the extent to which staff feel like their mistakes are not held against
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