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psnet.ahrq.gov/web-mm/breakage-picc-line
June 21, 2023 - SPOTLIGHT CASE
Breakage of a PICC Line
Citation Text:
Dimov V. Breakage of a PICC Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - As a result, appropriate actions and decisions can occur more quickly during emergencies.
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psnet.ahrq.gov/web-mm/electronic-err
April 01, 2014 - Electronic Err
Citation Text:
Tang PC. Electronic Err. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - Managing Ascites: Hazards of Fluid Removal
Citation Text:
Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/issue/improving-safety-and-security-veterans-act-2020
March 25, 2020 - Legislation/Case Law
Improving Safety and Security for Veterans Act of 2020.
Citation Text:
Improving Safety and Security for Veterans Act of 2020. HB 5616, 116th Congress: 2020.
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psnet.ahrq.gov/issue/va-pauses-16b-oracle-cerner-ehr-deployments-indefinitely-address-error-ridden-early-rollout
September 14, 2022 - Newspaper/Magazine Article
VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout.
Citation Text:
VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout. Muoio D. Fierce Healthcare. April 21, 2023.
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psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
January 29, 2021 - is now well recognized and has been labeled “well leg compartment syndrome”. 7,8,9 It is thought to occur … Take-Home Points Compartment syndrome in the lower leg can occur after operations in the lithotomy and
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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - million people annually are injured by medication errors in the United States, 7 and 80% of those errors occur … interdisciplinary bedside rounds had a significant impact on 7-day readmissions. 34 Team bedside rounds occur
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psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
March 07, 2012 - Pain may occur locally at the skin incision site, but the most common and concerning type of pain is
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psnet.ahrq.gov/node/42868/psn-pdf
October 31, 2014 - Communication-and-resolution programs: the challenges
and lessons learned from six early adopters.
October 31, 2014
Mello MM, Boothman RC, McDonald TB, et al. Communication-and-resolution programs: the challenges
and lessons learned from six early adopters. Health Aff (Millwood). 2014;33(1):20-29.
doi:10.1377/hlth…
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psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
December 23, 2020 - medication errors, are estimated to account for up to a third of all ADEs. 1 While medication errors can occur
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psnet.ahrq.gov/issue/collaborative-accountability-and-improvement
August 14, 2018 - Multi-use Website
Collaborative for Accountability and Improvement.
Citation Text:
Collaborative for Accountability and Improvement. University of Washington.
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psnet.ahrq.gov/issue/coding-success-simple-technology-safer-patient-care
July 01, 2020 - Book/Report
Coding for Success: Simple Technology for Safer Patient Care.
Citation Text:
Coding for Success: Simple Technology for Safer Patient Care. Healthcare Quality Directorate, Department of Health. London, UK; Crown Copyright: 2007.
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psnet.ahrq.gov/web-mm/crossed-coverage
September 01, 2015 - service also might not have prevented the error.( 5 ) The majority of preventable adverse drug events occur
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psnet.ahrq.gov/web-mm/wrongful-resuscitation
October 12, 2012 - Communication needs to occur early in the disease course.
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psnet.ahrq.gov/node/33872/psn-pdf
January 01, 2018 - engaged patients to help health care systems identify
safety hazards, regain trust after safety hazards occur
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psnet.ahrq.gov/node/33735/psn-pdf
August 01, 2012 - More severe events (i.e., serious, life-
threatening, or fatal events) occur at a rate of 2.5 per 100
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - reconciliation and review at patient entry and exit into the ICU, an intervention that is beginning to occur
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psnet.ahrq.gov/issue/ockenden-report-emerging-fndings-and-recommendations-independent-review-maternity-services
April 27, 2022 - Book/Report
Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust.
Citation Text:
Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at …
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psnet.ahrq.gov/issue/final-report-ockenden-review
January 13, 2021 - Book/Report
Final Report of the Ockenden Review.
Citation Text:
Final Report of the Ockenden Review. London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294.
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