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psnet.ahrq.gov/node/841199/psn-pdf
December 07, 2022 - houses collections of materials to support constructive communication should a failure or near-miss occur
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psnet.ahrq.gov/node/851927/psn-pdf
August 02, 2023 - https://psnet.ahrq.gov/issue/perioperative-handoffs
Handoffs occur several times during a surgical procedure
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psnet.ahrq.gov/node/844772/psn-pdf
September 18, 2019 - psnet.ahrq.gov/issue/lyme-disease-baffling-even-experts-new-insights-are-last-accumulating
Diagnostic errors occur
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psnet.ahrq.gov/node/73326/psn-pdf
June 01, 2021 - model was designed to support early error
disclosure with patients and families after mistakes in care occur
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psnet.ahrq.gov/node/50757/psn-pdf
December 18, 2019 - psnet.ahrq.gov/issue/university-hospital-hounds-debtors-doctors-say-its-doing-harm
Financial harms occur
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psnet.ahrq.gov/node/843322/psn-pdf
February 01, 2023 - psnet.ahrq.gov/issue/deadly-epidural-delivered-doctor-history-mistakes
Active errors are evident when they occur
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psnet.ahrq.gov/node/838326/psn-pdf
October 12, 2022 - people-color-long-covid-face-uphill-battle-be-heard
Gaslighting women and patients of color is known to occur
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psnet.ahrq.gov/node/73327/psn-pdf
January 25, 2022 - ismp-medication-safety-self-assessmentr-perioperative-settings
The perioperative setting is a high-risk area for medication errors, should they occur
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psnet.ahrq.gov/node/851658/psn-pdf
July 26, 2023 - This article summarizes potential
patient harm that can occur during hospitalization for older adults
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psnet.ahrq.gov/node/37752/psn-pdf
May 07, 2019 - been adopted in hospitals to prevent medication errors, but accidents
associated with their use still occur
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psnet.ahrq.gov/node/865702/psn-pdf
May 01, 2024 - psnet.ahrq.gov/issue/judgment-errors-surgical-care
Knowing when judgment errors are more likely to occur
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - occlusion, as in this case.
15
15
Tracheostomy Management (4)
Complications of tracheostomy can occur … can cause skin breakdown and require a plan for removal.5,7
Obstruction of the tracheostomy tube can occur … surgically placed tubes, due to healing times.1,15
If the type of placement is unknown, no change should occur … need to be familiar with what low versus high priority alarms sound like and what to do when these occur … a plan for the next tracheostomy change, an explanation of complications that have occurred or may occur
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psnet.ahrq.gov/node/60924/psn-pdf
September 16, 2020 - to support the focus of
reporting initiatives on the system rather than individuals when failures occur
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psnet.ahrq.gov/node/852458/psn-pdf
June 01, 2019 - patients to engage with their own safety and
how to effectively communicate with patients should an error occur
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psnet.ahrq.gov/node/838027/psn-pdf
September 07, 2022 - advancing-anticoagulation-stewardship-playbook
Warfarin and other anticoagulants are high-alert medications that, if errors occur
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psnet.ahrq.gov/node/842432/psn-pdf
January 11, 2023 - psnet.ahrq.gov/issue/medication-errors-year-review-january-through-december-2021
Medication errors continue to occur
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psnet.ahrq.gov/node/847057/psn-pdf
April 05, 2023 - This article discusses medication errors
that continue to occur despite established practices that,
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psnet.ahrq.gov/node/867340/psn-pdf
December 11, 2024 - multiple-points-system-failure-underpin-continuous-subcutaneous-infusion-
safety-incidents
Medication errors can occur
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psnet.ahrq.gov/node/851464/psn-pdf
July 19, 2023 - Impacts such as
psychological health of the patient and access to care units, should a crash occur,
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psnet.ahrq.gov/node/74749/psn-pdf
February 09, 2022 - information technology has improved many aspects of patient care, unintended negative
consequences may also occur