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psnet.ahrq.gov/node/42294/psn-pdf
May 22, 2013 - pervasive problem of diagnostic errors and reveals insights from
clinicians and patients on why they occur
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psnet.ahrq.gov/node/38767/psn-pdf
April 18, 2011 - with spinal anesthesia and describes strategies to minimize
errors and address failures when they occur
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psnet.ahrq.gov/node/865483/psn-pdf
April 03, 2024 - risks-analogue-and-digitally-supported-medication-process-and-potential-
solutions-increase
Medication errors can occur
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psnet.ahrq.gov/node/862601/psn-pdf
February 14, 2024 - Why simulation matters: a systematic review on medical
errors occurring during simulated health care.
February 14, 2024
Bokka L, Ciuffo F, Clapper TC. Why simulation matters: a systematic review on medical errors occurring
during simulated health care. J Patient Saf. 2024;20(2):110-118. doi:10.1097/pts.000000000000…
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - nutritional supplements are often overlooked by
providers and patients.7
Medication errors may occur … Hospital discharges are one example of a transition of care, and over 35 million hospital discharges occur … The Joint Commission Center for Transforming Healthcare reports
that communication breakdowns occur … Breakdowns in patient education can
occur when conflicting recommendations are made. … Accountability
breakdowns occur when there is no primary provider to take responsibility for assuring
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psnet.ahrq.gov/node/35396/psn-pdf
September 11, 2009 - The authors analyzed the drug administration process and where in the process errors are likely to
occur
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psnet.ahrq.gov/issue/managing-adverse-event-occurring-during-elective-ambulatory-pediatric-surgery
March 01, 2023 - Commentary
Managing the adverse event occurring during elective, ambulatory pediatric surgery.
Citation Text:
Skarsgard ED. Managing the adverse event occurring during elective, ambulatory pediatric surgery. Semin Pediatr Surg. 2009;18(2):122-4. doi:10.1053/j.sempedsurg.2009.02.013.
…
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psnet.ahrq.gov/node/859301/psn-pdf
January 01, 2024 - Misunderstandings were more likely to occur with higher numbers
and/or new prescriptions, poor medication-related
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psnet.ahrq.gov/node/845652/psn-pdf
March 14, 2023 - tactics to minimize controlled substance diversion, and track, document and
take action when it does occur
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psnet.ahrq.gov/node/74862/psn-pdf
February 23, 2022 - a crucial role in intravenous medication administration errors, and
deviations were more likely to occur
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psnet.ahrq.gov/node/73487/psn-pdf
July 14, 2021 - Results suggest robust resident training programs can limit errors that may otherwise occur during this
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psnet.ahrq.gov/node/46045/psn-pdf
December 22, 2018 - validating-domains-patient-contextual-factors-essential-preventing-contextual-
errors
Contextual errors can occur
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psnet.ahrq.gov/node/73139/psn-pdf
April 14, 2021 - medication and wrong dosage errors, and wrong patient, wrong form, and ambiguous
dispenser errors did not occur
-
psnet.ahrq.gov/node/838009/psn-pdf
September 07, 2022 - high-risk-medication-home-care-nursing-delphi-study
Medication errors and other adverse events are thought to occur
-
psnet.ahrq.gov/node/72794/psn-pdf
March 03, 2021 - otolaryngologists, surgical safety checklists were widely used, but intraoperative adverse
events continue to occur
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psnet.ahrq.gov/node/74726/psn-pdf
February 02, 2022 - Findings suggest that factors influencing effective disclosure occur on three levels:
interpersonal
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psnet.ahrq.gov/node/38124/psn-pdf
October 08, 2008 - missed-injuries-trauma-patients-literature-review
This review found that missed injuries and delayed diagnoses occur
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psnet.ahrq.gov/node/850933/psn-pdf
June 21, 2023 - prevalence-second-victim-syndrome-and-emotional-distress-pediatric-
intensive-care-providers
Preventable harm continues to occur
-
psnet.ahrq.gov/node/50750/psn-pdf
January 01, 2020 - yr-experience-cross-national-anaesthesia-
incident-reporting
Medication-related adverse events (MRE) occur
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psnet.ahrq.gov/node/40312/psn-pdf
June 10, 2018 - oops-sorry-wrong-patient-patient-verification-process-needed-everywhere-not-
just-bedside
This piece identifies situations in which patient verification errors occur