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psnet.ahrq.gov/issue/barcode-technology-its-role-increasing-safety-blood-transfusion
September 08, 2021 - March 20, 2019
Specimen labeling errors in surgical pathology: an 18-month experience
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psnet.ahrq.gov/issue/ensuring-medication-safety-consumers-ethnic-minority-backgrounds-need-address-unconscious
July 29, 2020 - June 30, 2021
"Talk About Your Medicines" Month.
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psnet.ahrq.gov/web-mm/insert-omission
May 09, 2014 - One month later, the patient presented to the clinic because she was unable to find the strings. … Follow-up should occur approximately 1 month after IUC placement for all patients.
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - A month after stopping steroids, the headaches recurred. … It was not clear if the 2-month delay would have long-term consequences beyond the untreated symptoms … inquired about the absence of an interpretation on an elevated CRP earlier, potentially shortening the 2-month
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psnet.ahrq.gov/issue/development-trigger-tool-identify-adverse-events-and-harm-emergency-medical-services
August 07, 2024 - January 11, 2023
Twelve-month review of infusion pump near-miss medication and dose selection
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psnet.ahrq.gov/issue/using-simulation-augment-root-cause-analysis-patient-safety-incidents-tertiary-care-womens
January 22, 2025 - View More
Related Resources
Learning in radiation oncology: 12-month
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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - https://psnet.ahrq.gov/web-mm/danger-disruption
The Case
A 23-month-old toddler was severely dehydrated … 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/issue/controlled-trial-rapid-response-system-academic-medical-center
June 23, 2010 - that implementation of an RRT at an academic medical center did not improve clinical outcomes over a 6-month
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psnet.ahrq.gov/issue/developing-and-evaluating-success-family-activated-medical-emergency-team-quality-improvement
December 02, 2014 - Since families called METs only between one to two times per month, the program was not felt to pose
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psnet.ahrq.gov/issue/what-happens-between-visits-adverse-and-potential-adverse-events-among-low-income-urban
February 22, 2011 - visits and discovered 86% experienced at least one adverse or potential adverse event during the 9-month
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psnet.ahrq.gov/issue/clinical-impact-and-frequency-anatomic-pathology-errors-cancer-diagnoses
March 28, 2012 - system to establish correlation error frequencies between cytologic and histologic samples during a 6-month
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psnet.ahrq.gov/issue/incidence-adverse-drug-events-two-large-academic-long-term-care-facilities
February 11, 2009 - More than 800 ADEs occurred during the 9-month study period, with nearly 42% deemed preventable.
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psnet.ahrq.gov/issue/indication-specific-opioid-prescribing-us-patients-medicaid-or-private-insurance-2017
August 02, 2017 - retrospective analysis of nationally representative outpatient claims data, researchers found that over a 4-6 month
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psnet.ahrq.gov/issue/exploring-sociotechnical-intersection-patient-safety-and-electronic-health-record
May 01, 2015 - negative safety implications of EHR implementation and ongoing use by analyzing interview data from a 30-month
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psnet.ahrq.gov/issue/detecting-unapproved-abbreviations-electronic-medical-record
August 08, 2018 - This system resulted in a significant reduction in the use of UAAs over the 6-month study period.
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psnet.ahrq.gov/issue/intervention-decrease-catheter-related-bloodstream-infections-icu
June 16, 2011 - The intervention was remarkably successful, nearly eliminating CRBSI entirely in most ICUs over an 18-month
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psnet.ahrq.gov/issue/well-defined-pediatric-icu-active-surveillance-using-nonmedical-personnel-capture-less
July 13, 2010 - Over a 15-month period, 2465 events were recorded, representing 5.4 events per day.
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psnet.ahrq.gov/issue/effect-pharmacist-intervention-clinically-important-medication-errors-after-hospital
May 08, 2017 - pharmacist-driven intervention still experienced a clinically important medication error within one month
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psnet.ahrq.gov/issue/crushing-or-splitting-medications-unrecognized-hazards
October 26, 2010 - October 5, 2022
"Talk About Your Medicines" Month.
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psnet.ahrq.gov/node/866265/psn-pdf
July 31, 2024 - misplaced-vial-medication-kit-variability-contributes-medication-error-
during-patient
The Case
A 19-month-old … Reference (Improved)
The Commentary
By Paul MacDowell, PharmD, BCPS, and Eloh McGee, PharmD
A 19-month-old