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psnet.ahrq.gov/node/37354/psn-pdf
November 21, 2007 - fires-during-surgeries-bigger-risk-thought
This article reports data suggesting that the number of surgical fires that occur
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psnet.ahrq.gov/node/42725/psn-pdf
November 13, 2013 - audit-missed-or-delayed-antimicrobial-drugs
This record review study found that omitted doses of antimicrobial medications occur
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psnet.ahrq.gov/perspective/conversation-cheryl-jones-about-addressing-workplace-violence-and-creating-safer
October 31, 2023 - employ large numbers of healthcare professionals, with opportunities for workplace violence events to occur … we think that certain units may have a patient population that may predispose workplace violence to occur … In recent years, in addition to workplace violence events that may occur in healthcare organizations, … challenges with reporting and making it easier for clinicians to report acts of violence when they occur … Having reporting systems in place that facilitate the reporting of events when they actually occur is
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psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
October 31, 2023 - tagged PubMedId RIS
Download Citation
While violence in the workplace can occur … stalking, and sexual harassment. 5
Perpetrators of workplace violence can vary, and violence can occur … we think that certain units may have a patient population that may predispose workplace violence to occur … In recent years, in addition to workplace violence events that may occur in healthcare organizations, … Having reporting systems in place that facilitate the reporting of events when they actually occur is
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psnet.ahrq.gov/node/49476/psn-pdf
March 02, 2005 - And, perhaps
most importantly, how did this series of events occur despite the presence of the warning … list_uids=11342094
https://psnet.ahrq.gov//#references
Preoperative LMWH
Needle placement should occur … avoided in patients administered a dose of LMWH 2 hours
preoperatively, because needle placement would occur … The second postoperative dose should occur no sooner than 24 hours after the first
dose. … Subsequent LMWH dosing should
occur a minimum of 2 hours after catheter removal.
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psnet.ahrq.gov/node/867633/psn-pdf
February 26, 2025 - preventable and
that healthcare systems should be able to rapidly identify and treat complications when they occur
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psnet.ahrq.gov/node/865877/psn-pdf
May 15, 2024 - The revised
framework identifies critical points where communication breakdowns are likely to occur
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psnet.ahrq.gov/node/36604/psn-pdf
June 04, 2024 - 15th-annual-public-report
The National Quality Forum has defined 29 never events—patient safety problems that should never occur
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psnet.ahrq.gov/node/860732/psn-pdf
April 16, 2024 - retained-swabs-following-invasive-procedures-themes-identified-review-nhs-
serious-incident
Retained surgical items are never events that continue to occur
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psnet.ahrq.gov/node/39756/psn-pdf
August 11, 2010 - which an oral medication, nimodipine, was administered
intravenously and describes how such errors occur
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psnet.ahrq.gov/node/38730/psn-pdf
June 24, 2009 - errors-clinical-reasoning-causes-and-remedial-strategies
This commentary analyzes how cognitive errors occur
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psnet.ahrq.gov/node/35491/psn-pdf
July 12, 2018 - author emphasizes the complexity of decision making in obstetric care to illustrate how mistakes can
occur
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psnet.ahrq.gov/node/37578/psn-pdf
May 02, 2018 - /issue/keeping-patients-safe-iatrogenic-methadone-overdoses
This article describes errors that can occur
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psnet.ahrq.gov/node/837300/psn-pdf
June 01, 2022 - https://psnet.ahrq.gov/issue/surgery-itself-risk-factor-patient
Preventable adverse events (AE) can occur
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psnet.ahrq.gov/node/838312/psn-pdf
October 12, 2022 - causes-adverse-events-home-mechanical-ventilation-nursing-perspective
Hospital-level care at home can reduce cost and hospital readmissions, but adverse events still occur
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psnet.ahrq.gov/node/838029/psn-pdf
September 07, 2022 - emergency-preparedness-be-ready-unanticipated-electronic-health-record-ehr-
downtime
Unanticipated health information system downtime can occur
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psnet.ahrq.gov/node/846756/psn-pdf
March 29, 2023 - the majority of studies as administration greater than 60 minutes before or after the scheduled time) occur
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psnet.ahrq.gov/node/60949/psn-pdf
September 23, 2020 - can assign accountability appropriately while encouraging disclosure and improvement when
mistakes occur
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psnet.ahrq.gov/node/837974/psn-pdf
August 31, 2022 - healthcare balances organizational and individual responsibility and accountability when
medical errors occur
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psnet.ahrq.gov/node/73295/psn-pdf
May 19, 2021 - bupivacaine-
hydrochloride-injection-usp
Anesthesia medications can be high risk should dosing errors occur