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  1. 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
  2. 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
  3. 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
  4. 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
  5. 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…
  6. 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…
  7. 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…
  8. 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…
  9. psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
    August 20, 2018 - toxicities related to opioid misuse increased by 134% from 2004 to 2010.( 3 ) Drug-related adverse events occur … Second, pharmacotherapy with opioid medications to treat opioid addiction requires that an evaluation occur … treatment, the use of an antagonist that can block the euphoria-producing effects of opioids should relapse occur … agonist effects with naltrexone will eliminate the potential for respiratory depression that might occur
  10. 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…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49812/psn-pdf
    November 01, 2017 - Preanalytic error, as occurred in this case, typically involves the steps of laboratory testing that occur … Discovery of preanalytic error can occur at any stage of health care delivery. … will be lost or misprocessed are listed in the Table .(5) Laboratory errors including specimen loss occur
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49791/psn-pdf
    April 01, 2017 - Despite the introduction of the Universal Protocol, wrong-site errors or near misses continue to occur … Site verification and marking should occur by reconciling all critical information including history … wrong-site error.(10,11) In the context of a regional anesthesia procedure, a team or block time-out should occur
  13. Psn-Pdf (pdf file)

    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
  14. Psn-Pdf (pdf file)

    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
  15. 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…
  16. 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…
  17. 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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  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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