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  1. Psn-Pdf (pdf file)

    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
  2. Psn-Pdf (pdf file)

    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
  3. Psn-Pdf (pdf file)

    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
  4. Psn-Pdf (pdf file)

    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
  5. Psn-Pdf (pdf file)

    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
  6. Psn-Pdf (pdf file)

    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
  7. Psn-Pdf (pdf file)

    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
  8. Psn-Pdf (pdf file)

    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
  9. Psn-Pdf (pdf file)

    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
  10. Psn-Pdf (pdf file)

    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
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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