-
psnet.ahrq.gov/node/43904/psn-pdf
October 13, 2015 - reducing-unacceptable-missed-doses-pharmacy-assistant-supported-
medicine-administration
Omitted or delayed medication doses occur
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psnet.ahrq.gov/node/40600/psn-pdf
September 09, 2011 - Quality Forum first defined a set of never events to highlight significant errors that should
never occur
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psnet.ahrq.gov/node/47876/psn-pdf
March 27, 2019 - Inadequate communication during handoffs that occur as part of care
transitions can contribute to adverse
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psnet.ahrq.gov/node/45425/psn-pdf
December 22, 2018 - an excessive number of safety warnings that prescribers must manually override, alert fatigue
may occur
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psnet.ahrq.gov/node/47058/psn-pdf
August 20, 2018 - for improving the safety and
quality of health care, consistent use of known best practices does not occur
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psnet.ahrq.gov/node/42900/psn-pdf
September 19, 2016 - The majority of inpatient suicides
occur in psychiatric units, but a prior Joint Commission sentinel
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psnet.ahrq.gov/node/39822/psn-pdf
February 17, 2011 - what
information to share and how to share it; of course, discussions about individual disclosure occur
-
psnet.ahrq.gov/node/37462/psn-pdf
January 06, 2017 - medication-errors-associated-code-situations-us-hospitals-direct-and-
collateral-damage
This study describes medication error types that occur
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psnet.ahrq.gov/node/42693/psn-pdf
December 23, 2016 - Despite being
long recognized as a critical—and preventable—error, RFOs continue to occur, with nearly
-
psnet.ahrq.gov/node/42103/psn-pdf
January 07, 2015 - electronic medical
records, errors such as entering notes or ordering medications for the wrong patient may 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/49552/psn-pdf
January 01, 2008 - Some physicians may even feel "permanently
wounded" as a result.(9) These feelings appear to occur regardless … support, however, a key question is what other means of support are available for
providers after errors occur … surprising that there
are relatively few formal support programs available for providers after errors occur … Suggested forums for processing errors include case reviews, which may occur informally in small groups
-
psnet.ahrq.gov/node/60980/psn-pdf
January 01, 2022 - Analysis of risk factors for patient safety events occurring
in the emergency department.
October 7, 2020
Alsabri M, Boudi Z, Zoubeidi T, et al. Analysis of risk factors for patient safety events occurring in the
emergency department. J Patient Saf. 2022;18(1):e124-e135. doi:10.1097/pts.0000000000000715.
https://p…
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psnet.ahrq.gov/node/37533/psn-pdf
April 22, 2011 - Systematic evaluation of errors occurring during the
preparation of intravenous medication.
April 22, 2011
Parshuram CS, To T, Seto W, et al. Systematic evaluation of errors occurring during the preparation of
intravenous medication. CMAJ. 2008;178(1):42-8. doi:10.1503/cmaj.061743.
https://psnet.ahrq.gov/issue/sys…
-
psnet.ahrq.gov/node/35876/psn-pdf
June 18, 2013 - External Inquiry into the adverse incident that occurred at
Queen's Medical Centre, Nottingham, 4th January 2001.
June 18, 2013
Toft B. London, UK; Crown Copyright: 2001.
https://psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham-
4th-january-2001
This UK Department o…
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psnet.ahrq.gov/node/42993/psn-pdf
March 19, 2014 - Baccalaureate nursing students' accounts of medical
mistakes occurring in the clinical setting: implications for
curricula.
March 19, 2014
Noland CM. Baccalaureate nursing students' accounts of medical mistakes occurring in the clinical setting:
implications for curricula. J Nurs Educ. 2014;53(3):S34-7. doi:10.392…
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psnet.ahrq.gov/node/37156/psn-pdf
October 06, 2011 - Preventable harm occurring to critically ill children.
October 6, 2011
Larsen G, Donaldson AE, Parker HB, et al. Preventable harm occurring to critically ill children. Pediatr Crit
Care Med. 2007;8(4):331-336.
https://psnet.ahrq.gov/issue/preventable-harm-occurring-critically-ill-children
This retrospective cohort…
-
psnet.ahrq.gov/node/39743/psn-pdf
October 13, 2010 - Anatomy and pathophysiology of errors occurring in
clinical radiology practice.
October 13, 2010
Brook OR, O'Connell AM, Thornton E, et al. Quality initiatives: anatomy and pathophysiology of errors
occurring in clinical radiology practice. Radiographics. 2010;30(5):1401-10. doi:10.1148/rg.305105013.
https://psnet…
-
psnet.ahrq.gov/node/37155/psn-pdf
October 06, 2011 - Classification of adverse events occurring in a surgical
intensive care unit.
October 6, 2011
Frankel H, Sperry J, Kaplan L, et al. Classification of adverse events occurring in a surgical intensive care
unit. Am J Surg. 2007;194(3):328-32.
https://psnet.ahrq.gov/issue/classification-adverse-events-occurring-surgi…
-
psnet.ahrq.gov/node/38360/psn-pdf
March 18, 2010 - Medication errors occurring with the use of bar-code
administration technology.
March 18, 2010
PA-PSRS Patient Saf Advis. December 2008;5:122-126.
https://psnet.ahrq.gov/issue/medication-errors-occurring-use-bar-code-administration-technology
This article describes errors associated with bar coded medication admin…