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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.182_slideshow.ppt
September 01, 2008 - forgotten” by physician, but patient cannot bear stopping it
If daily dose continued for more than month … given
To relieve single painful, inflamed joint, use of intraarticular glucocorticoids at 2- to 3-month … intervals
Use of oral glucocorticoids only in protocols where tapered to zero dose within a month
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psnet.ahrq.gov/issue/july-spike-fatal-medication-errors-possible-effect-new-medical-residents
February 15, 2011 - Investigators discovered that fatal medication errors spiked by 10% in July and in no other month.
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psnet.ahrq.gov/issue/hassle-dispensary-pilot-study-proactive-risk-monitoring-tool-organisational-learning-based
January 21, 2015 - issues with the work environment and information technology, were then prospectively monitored over a 6-month
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psnet.ahrq.gov/issue/identifying-potential-predictors-safe-attending-physician-workload-survey-hospitalists
December 21, 2014 - attending hospitalists, 40% of respondents reported an unsafe, high workload at least once in the prior month
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psnet.ahrq.gov/issue/elimination-central-venous-catheter-related-bloodstream-infections-intensive-care-unit
January 11, 2017 - program resulted in the complete elimination of catheter-related bloodstream infections for a 19-month
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psnet.ahrq.gov/issue/pharmaceutical-interventions-improve-safety-chemotherapy-treated-cancer-patients-cross
March 10, 2011 - this prospective study, researchers found that 129 of 1346 chemotherapy prescriptions issued in a 1-month
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psnet.ahrq.gov/issue/comprehensive-evaluation-using-computerised-provider-order-entry-system-hospital-discharge
August 24, 2015 - This French hospital analyzed hospital discharge orders (HDO) over a six-month period to evaluate the
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psnet.ahrq.gov/issue/prescribing-errors-low-molecular-weight-heparins
July 26, 2017 - body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month
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psnet.ahrq.gov/issue/epidemiology-adverse-events-and-medical-errors-care-cardiology-patients
November 26, 2014 - cross-sectional study of adult cardiology outpatients at a single Japanese teaching hospital over a 10-month
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psnet.ahrq.gov/issue/embracing-errors-simulation-based-training-effect-error-training-retention-and-transfer
May 23, 2013 - immediate postcourse tests, but the group that included error training performed significantly better one month
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psnet.ahrq.gov/issue/acgme-summary-report-pursuing-excellence-pathway-leaders-patient-safety-collaborative
October 18, 2017 - This report highlights results of an 18-month collaborative to design tactics that engage resident and
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psnet.ahrq.gov/issue/crisis-undiagnosed-cancers-emerging-pandemics-second-year
November 30, 2022 - June 8, 2022
The impact of a 22-month multistep implementation program on speaking-up
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psnet.ahrq.gov/issue/multi-method-exploratory-evaluation-service-designed-improve-medication-safety-patients
July 22, 2020 - referrals were completed post-intervention, but 45% were not completed at all or took longer than one month
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psnet.ahrq.gov/issue/process-failures-increase-risk-infection-through-respiratory-droplets-study-patient-safety
March 24, 2021 - pertussis, meningitis, measles) reported to the Pennsylvania Patient Safety Reporting System over a 12-month
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psnet.ahrq.gov/issue/enhancing-teamwork-communication-and-patient-safety-responsiveness-paediatric-intensive-care
March 10, 2021 - Over a 7-month period, 340 safety issues were addressed; the majority involved infection control and
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psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
February 14, 2024 - The Case A 2-month-old boy was brought in for a routine 2-month well-child visit.
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psnet.ahrq.gov/issue/lessons-denver-medication-errorcriminal-negligence-case-look-beyond-blaming-individuals
June 16, 2019 - May 22, 2013
Spike in fatal medication errors at the beginning of each month.
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psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction … The fact that the 23-month-old child eventually received intravenous fluids and had no sequelae from … doing the opposite: celebrating positive behavior and collegiality by honoring a "Physician of the Month
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psnet.ahrq.gov/node/45759/psn-pdf
July 11, 2017 - In academic hospitals, clinician teams switch on a predictable schedule, often at
the end of the month
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psnet.ahrq.gov/submit-your-toolkit-landing
Decision
You will receive notification within one month regarding whether