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Showing results for "mistakes".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49686/psn-pdf
    May 01, 2013 - Don't Use That Port: Insert a PICC May 1, 2013 Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc The Case A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with fever and abdominal pain. A comp…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49560/psn-pdf
    April 01, 2008 - The Wrongful Resuscitation April 1, 2008 Teno JM. The Wrongful Resuscitation. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/wrongful-resuscitation The Case   An 80-year-old man with diabetes, peripheral vascular disease, bilateral below-the-knee amputations, and poor quality of life had previously been r…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49447/psn-pdf
    June 01, 2004 - Dangerous Dapsone June 1, 2004 Bookwalter T. Dangerous Dapsone. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/dangerous-dapsone The Case A 78-year-old woman with newly diagnosed multiple myeloma on corticosteroids presented to the emergency department with dyspnea. Upon admission, she was found to be hypo…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33581/psn-pdf
    December 15, 2024 - Medication Errors and Adverse Drug Events December 15, 2024 Medication Errors and Adverse Drug Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect cu…

  5. If You Say So: Taking a Syringe at Face Value in the Operating Room | PSNet

    psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
    January 01, 2015 - If You Say So: Taking a Syringe at Face Value in the Operating Room Citation Text: Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cita…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49572/psn-pdf
    October 01, 2008 - Mistaken Identity October 1, 2008 Hall LW. Mistaken Identity. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/mistaken-identity The Case An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status and a reported fall. After finding tenderness in her left hip, the p…

  7. Transfusion "Slip" | PSNet

    psnet.ahrq.gov/web-mm/transfusion-slip
    June 14, 2011 - Transfusion "Slip" Citation Text: Kaplan HS. Transfusion "Slip". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  8. Patient Safety Executive Walkarounds (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Graham.pdf
    April 01, 2004 - Patient Safety Executive Walkarounds 223 Patient Safety Executive Walkarounds Suzanne Graham, John Brookey, Catherine Steadman Abstract Since the release of the IOM report To Err Is Human in 1999, significant progress has been made in patient safety. One of the remaining challenges is the need to continually…

  9. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. | PSNet

    psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
    January 23, 2017 - design such as how medications are manufactured and packaged) and active errors (i.e., slips, lapses, or mistakes … closed-loop communication. 42 Medication error reporting The safest organizations learn from their mistakes

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60952/psn-pdf
    September 30, 2020 - Early in the career of the freshly graduated physician, there are many things to learn and many mistakes

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33656/psn-pdf
    September 01, 2007 - frustrated after we realized in the last several years that we had no idea if we were making fewer mistakes

  12. On the Other Hand | PSNet

    psnet.ahrq.gov/web-mm/other-hand
    December 12, 2012 - MEDtoos—Temporary tattoos to prevent wrong-site, wrong person, wrong-procedure medical mistakes.

  13. The CAHPS Ambulatory Care Improvement Guide: Ways to Approach the Quality Improvement Process (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/4-approach-qi-process/cahps-section-4-ways-to-approach-qi-process.pdf
    May 17, 2017 - The CAHPS Ambulatory Care Improvement Guide: Ways to Approach the Quality Improvement Process The CAHPS Ambulatory Care Improvement Guide Practical Strategies for Improving Patient Experience Section 4: Ways to Approach the Quality Improvement Process Visit the AHRQ Website for the full Guide. May 2017 (upda…

  14. Diagnosing a Missed Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
    October 26, 2022 - Mental Health Care (Psychiatry and Clinical Psychology) Clinical Misdiagnosis Cognitive Errors ("Mistakes

  15. Who Nose Where the Airway Is? | PSNet

    psnet.ahrq.gov/web-mm/who-nose-where-airway
    May 01, 2016 - May 22, 2019 WebM&M Cases Vial Mistakes Involving Heparin

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33769/psn-pdf
    June 01, 2014 - Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans

  17. Final Progress Report: How Do Consumers View the Risks of Medical Errors? (pdf file)

    www.ahrq.gov/sites/default/files/2024-07/peters-report.pdf
    January 01, 2024 - Inhibition System [BIS] scale,11 e.g., “Criticism or scolding hurts me quite a bit,” “I worry about making mistakes

  18. Complications of Vascular Access Procedures in Patients with Kidney Disease | PSNet

    psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
    November 15, 2023 - Arrest January 26, 2022 WebM&M Cases Vial Mistakes

  19. Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
    March 12, 2008 - Both of these errors were due to mistakes made by pharmacy, which loads the bulk medications into the

  20. Death by PCA | PSNet

    psnet.ahrq.gov/web-mm/death-pca
    January 06, 2017 - designing safer user interfaces ( 8 ), the majority of errors still originate with individuals making mistakes
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