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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
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psnet.ahrq.gov/node/33811/psn-pdf
June 01, 2016 - the use of SBAR
(situation, background, assessment, recommendation), yet medical errors continue to occur … They are truly affected by the tragedies that occur
in the literature.
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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/issue/potentially-severe-incidents-during-interhospital-transport-critically-ill-patients
October 26, 2022 - Study
Potentially severe incidents during interhospital transport of critically ill patients, frequently occurring but rarely reported: a prospective study.
Citation Text:
Eiding H, Røise O, Kongsgaard UE. Potentially severe incidents during interhospital transport of critically ill pati…
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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…
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - be the review of a checklist, some have argued that asking open-ended questions, such as those that occur … While the Universal Protocol currently mandates that a time out occur immediately prior to the procedure … , some have suggested that a debriefing occur after the procedure as well.( 1 ) Finally, documentation … Furthermore, in hospitals where time outs occur regularly and with meaning, it is the attending surgeon
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psnet.ahrq.gov/node/45814/psn-pdf
March 22, 2017 - emergency-medical-services-responders-perceptions-effect-stress-and-
anxiety-patient-safety
Prehospital emergencies are time critical, and they occur
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psnet.ahrq.gov/node/47605/psn-pdf
January 17, 2019 - nonpayment for the procedures themselves and any consequent care, these serious surgical errors
continue to occur
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psnet.ahrq.gov/node/43589/psn-pdf
November 17, 2014 - Diagnosis-related concerns were estimated to occur in 0.5% of all
hospital admissions.
-
psnet.ahrq.gov/node/44881/psn-pdf
August 16, 2017 - -
tertiary-care
The surgical safety checklist has generally been evaluated based on outcomes that occur
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psnet.ahrq.gov/node/46245/psn-pdf
June 28, 2017 - associations-between-patient-factors-and-adverse-events-home-care-setting-
secondary-data
Adverse events occur
-
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…
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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…
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psnet.ahrq.gov/node/867137/psn-pdf
November 13, 2024 - Enteral nutrition: an underappreciated source of patient
safety events.
November 13, 2024
Citty SW, Chew M, Hiller LD, et al. Enteral nutrition: an underappreciated source of patient safety events.
Nutr Clin Prac. 2024;39(4):784-799. doi:10.1002/ncp.11153.
https://psnet.ahrq.gov/issue/enteral-nutrition-underapprec…
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psnet.ahrq.gov/node/73067/psn-pdf
March 24, 2021 - Changes in error patterns in unanticipated trauma deaths
during 20 years: in pursuit of zero preventable deaths.
March 24, 2021
LaGrone LN, McIntyre LK, Riggle A, et al. Changes in error patterns in unanticipated trauma deaths during
20 years: In pursuit of zero preventable deaths. J Trauma Acute Care Surg. 2020;89…
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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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psnet.ahrq.gov/node/73603/psn-pdf
August 18, 2021 - The patients' perspective: hematological cancer patients'
experiences of adverse events as part of care.
August 18, 2021
Bryant J, Carey M, Sanson-Fisher R, et al. The patients' perspective: hematological cancer patients'
experiences of adverse events as part of care. J Patient Saf. 2021;17(5):e387-e392.
doi:10.10…