-
psnet.ahrq.gov/node/37580/psn-pdf
March 05, 2008 - patient-safety-events-reported-general-practice-taxonomy
This study provides a proposed three-level taxonomy for common events that occur
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psnet.ahrq.gov/node/36898/psn-pdf
February 01, 2011 - This shift involves increasing recognition that errors do
occur and that the health care system is flawed
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psnet.ahrq.gov/node/35780/psn-pdf
July 20, 2010 - paramedic-intubation-errors-isolated-events-or-symptoms-larger-problems
The investigators found that errors occur
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psnet.ahrq.gov/node/36650/psn-pdf
January 05, 2017 - analyzed intralipid medication error reports submitted to the Medmarx database and found
that most errors occur
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psnet.ahrq.gov/node/38402/psn-pdf
February 11, 2009 - used information from nurses, pharmacists, and patients to classify the types of
near misses that occur
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psnet.ahrq.gov/node/38689/psn-pdf
June 10, 2009 - This study discovered that drug omissions and unjustified medications listed in discharge summaries occur
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - occlusion, as in this case.
15
15
Tracheostomy Management (4)
Complications of tracheostomy can occur … can cause skin breakdown and require a plan for removal.5,7
Obstruction of the tracheostomy tube can occur … surgically placed tubes, due to healing times.1,15
If the type of placement is unknown, no change should occur … need to be familiar with what low versus high priority alarms sound like and what to do when these occur … a plan for the next tracheostomy change, an explanation of complications that have occurred or may occur
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psnet.ahrq.gov/node/867444/psn-pdf
January 08, 2025 - medication-errors-and-error-chains-involving-high-alert-medications-paediatric-
hospital
Understanding how and when medication errors occur
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psnet.ahrq.gov/node/867523/psn-pdf
January 15, 2025 - ) are rare, healthcare organizations must maintain policies on
LSAE disclosure (LSAED) should they occur
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psnet.ahrq.gov/node/866636/psn-pdf
January 01, 2025 - errors and concerns,
and having a formal process to identify and notify patients when diagnostic errors occur
-
psnet.ahrq.gov/node/38649/psn-pdf
May 20, 2009 - Managing the adverse event occurring during elective,
ambulatory pediatric surgery.
May 20, 2009
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.
https://psnet.ahrq.gov/issue/managing-advers…
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psnet.ahrq.gov/node/35915/psn-pdf
May 10, 2006 - for medical malpractice litigation and discusses what, from the legal
perspective, should ideally occur
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psnet.ahrq.gov/node/41879/psn-pdf
January 18, 2013 - retrieval-iatrogenic-intravascular-foreign-bodies
This review article characterizes the types of clinical issues that can occur
-
psnet.ahrq.gov/node/44917/psn-pdf
November 30, 2016 - canadian-incident-analysis-framework
Performing incident analysis can help organizations understand why adverse events occur
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psnet.ahrq.gov/node/43381/psn-pdf
July 30, 2014 - For instance, wrong-site surgeries continue to occur despite
garnering major attention over the past
-
psnet.ahrq.gov/node/43215/psn-pdf
May 28, 2014 - medical students to be educated about how to disclose
errors to patients and families when mistakes occur
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psnet.ahrq.gov/node/37265/psn-pdf
May 02, 2018 - potassium-may-no-longer-be-stocked-patient-care-units-serious-threats-still-
exist
This article describes how errors involving potassium chloride still occur
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psnet.ahrq.gov/node/44354/psn-pdf
August 05, 2015 - children for occult fractures—in several
clinically indicated situations, and found that such errors occur
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psnet.ahrq.gov/node/44007/psn-pdf
April 01, 2015 - pressure as a factor in diagnostic error, this magazine article describes efforts to
understand why they occur
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psnet.ahrq.gov/node/39262/psn-pdf
March 04, 2011 - issue/unintended-errors-ehr-based-result-management-case-series
The authors identify errors that may occur