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psnet.ahrq.gov/issue/evaluation-detected-medication-errors-within-operating-room-academic-medical-center
October 19, 2022 - This retrospective chart review of 145 surgical patients over a two-month period found that 98.6% of
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psnet.ahrq.gov/issue/hospitalization-and-death-associated-potentially-inappropriate-medication-prescriptions-among
August 04, 2021 - than 3300 nursing home residents, investigators reported greater odds of being hospitalized in the month
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psnet.ahrq.gov/issue/medication-order-errors-hospital-admission-among-children-medical-complexity
July 20, 2022 - examined 1,233 pediatric hospitalizations among children with complex medication conditions over a 12-month
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psnet.ahrq.gov/issue/burden-healthcare-utilization-cost-and-mortality-associated-select-surgical-site-infections
October 09, 2024 - Patients with SSI after orthopedic procedures had significantly higher 12-month mortality compared to
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psnet.ahrq.gov/issue/opioid-prescribing-decreases-after-learning-patients-fatal-overdose
January 18, 2023 - to the patients of providers who received the death notifications decreased by almost 10% in the 3-month
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psnet.ahrq.gov/issue/opioid-stewardship-program-and-postoperative-adverse-events-difference-differences-cohort
June 30, 2021 - This article discusses the impact of a 6-month opioid use educational program for anesthesiologists on
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psnet.ahrq.gov/issue/pact-collaborative-pathway-accountability-compassion-and-transparency
February 05, 2014 - This 18-month learning collaborative will help participants engage leadership , implement CRP processes
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psnet.ahrq.gov/issue/medication-errors-attributed-health-information-technology
March 27, 2018 - Drawing from 889 medication error reports submitted over a 6-month period, this analysis found that more
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psnet.ahrq.gov/issue/please-dont-sleep-through-wake-call
May 07, 2018 - The error involved administration of morphine to a 9-month-old infant who received 5 mg instead of 0.5
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psnet.ahrq.gov/issue/omission-high-alert-medications-hidden-danger
January 11, 2017 - Analyzing incidents reported over a 4-month period, this article reveals that 21% of 2700 medication
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psnet.ahrq.gov/node/46954/psn-pdf
January 23, 2019 - to the patients
of providers who received the death notifications decreased by almost 10% in the 3-month
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psnet.ahrq.gov/node/43436/psn-pdf
August 13, 2014 - This quality improvement initiative aimed to enhance
handoffs in 23 children's hospitals over a 12-month
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psnet.ahrq.gov/node/45535/psn-pdf
January 23, 2017 - primer/diagnostic-errors
https://psnet.ahrq.gov/issue/specimen-labeling-errors-surgical-pathology-18-month-experience
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psnet.ahrq.gov/node/45778/psn-pdf
April 26, 2017 - prescriptions remained lower in the group receiving the
orally communicated recommendations at 24-month
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psnet.ahrq.gov/node/44646/psn-pdf
November 11, 2015 - At this hospital, there
were 212 incorrect counts (potential retained foreign objects) over a 9-month
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
May 01, 2018 - testing was ordered for follow-up and monitoring.
4
Case: Out-of-Office Test Result Management (2)
A month … It was not clear if the 2-month delay would have long-term consequences beyond the untreated symptoms … have inquired about the absence of an interpretation on his elevated CRP, potentially shortening the 2-month
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psnet.ahrq.gov/issue/reducing-automated-dispensing-cabinet-overrides-peri-anesthesia-care-unit-quality-improvement
June 07, 2023 - The overall override rate decreased from 17% to 4% by the end of the 18-month project period, with a
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psnet.ahrq.gov/issue/medication-errors-care-transition-trauma-patients
September 02, 2020 - transitions for all patients admitted to the trauma service unit of a hospital in Madrid, Spain over a four-month
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psnet.ahrq.gov/issue/fall-prevention-smart-socks-system-reduces-hospital-fall-rates
September 09, 2020 - Over a 13-month period, investigators observed a decreased fall rate (0 per 1000 patient days) among
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psnet.ahrq.gov/node/35424/psn-pdf
April 09, 2013 - system to establish correlation error frequencies between cytologic
and histologic samples during a 6-month