-
psnet.ahrq.gov/node/73356/psn-pdf
June 02, 2021 - resonance imaging (MRI) suites harbor unique hazards that can harm patients, should process
missteps occur
-
psnet.ahrq.gov/node/839831/psn-pdf
November 09, 2022 - events serve as triggers to motivate substantive improvement in health care organizations should
they occur
-
psnet.ahrq.gov/node/846764/psn-pdf
March 29, 2023 - health record (EHR) systems are complex efforts that have the potential for
injury, should failure occur
-
psnet.ahrq.gov/node/849123/psn-pdf
May 17, 2023 - maximizing-student-potential-lessons-pharmacy-programs-patient-safety-
movement
The patient safety movement recognizes that most errors occur
-
psnet.ahrq.gov/node/73524/psn-pdf
July 21, 2021 - types of errors that compromise the safety of compounding
practices, steps in the process where they occur
-
psnet.ahrq.gov/node/73469/psn-pdf
July 07, 2021 - barriers-and-facilitators-bedside-nursing-handover-systematic-review-and-
meta-synthesis
Handovers between providers occur
-
psnet.ahrq.gov/node/844791/psn-pdf
September 18, 2019 - review-alternatives-root-cause-analysis-developing-robust-system-incident-
report-analysis
Root cause analysis is a fundamental approach to understanding how failures occur
-
psnet.ahrq.gov/node/847043/psn-pdf
April 05, 2023 - evidence-synthesis-perioperative-handoffs-call-balanced-sociotechnical-
solutions
Multiple handoffs occur
-
psnet.ahrq.gov/node/850353/psn-pdf
June 14, 2023 - perioperative-handoff-enhancement-opportunities-through-technology-and-
artificial
Multiple handoffs can occur
-
psnet.ahrq.gov/node/836721/psn-pdf
March 09, 2022 - sources-medication-omissions-among-hospitalized-older-adults-polypharmacy
Medication reconciliations, including conducting a best possible medication history (BPMH), may occur
-
psnet.ahrq.gov/node/35152/psn-pdf
July 13, 2005 - https://psnet.ahrq.gov/issue/not-what-doctor-ordered
This article reports on the types of errors that occur
-
psnet.ahrq.gov/node/73106/psn-pdf
April 01, 2021 - It graphically depicts the frequency with which various values of a variable occur in a set of data. … Run charts are useful in discovering patterns that occur over time. … inherent in the system) from special cause variation (due to
unexpected and unpredictable causes that occur
-
psnet.ahrq.gov/node/73168/psn-pdf
April 21, 2021 - ://psnet.ahrq.gov/web-mm/another-fall
https://psnet.ahrq.gov/issue/do-falls-and-other-safety-issues-occur-more-often-during-handovers-when-nurses-are-away
-
psnet.ahrq.gov/node/48161/psn-pdf
January 01, 2021 - investigating-impact-intensive-care-unit-interruptions-patient-safety-events-
and-electronic
Despite many technological innovations, safety events occur
-
psnet.ahrq.gov/node/74754/psn-pdf
February 09, 2022 - Results indicate that adverse events can occur in intra-hospital transport, and that frequency of
critical
-
psnet.ahrq.gov/node/49514/psn-pdf
July 01, 2006 - worrisome adverse effects (hypotension, renal
insufficiency, angioedema, and hyperkalemia) tend to occur … Points
The addition of a new medication requires monitoring for adverse drug events, which typically occur …
Digoxin (acute overdose) Hyperkalemia following acute overdose predicts poor outcome
Heparin Can occur …
Potassium supplements
Potassium-sparing diuretics
(amiloride, triamterene)
Hyperkalemia can occur
-
psnet.ahrq.gov/node/860732/psn-pdf
April 16, 2024 - retained-swabs-following-invasive-procedures-themes-identified-review-nhs-
serious-incident
Retained surgical items are never events that continue to occur
-
psnet.ahrq.gov/node/40971/psn-pdf
June 01, 2012 - iatrogenic-psychological-harm
This review discusses iatrogenic psychological harm, including how it may occur
-
psnet.ahrq.gov/node/35972/psn-pdf
June 17, 2014 - https://psnet.ahrq.gov/issue/patient-safety-ed
The authors discuss the kinds of errors that occur in
-
psnet.ahrq.gov/node/865873/psn-pdf
May 15, 2024 - review-medication-errors-and-second-victim-pediatric-pharmacy
Even with technology designed to prevent them, medication errors continue to occur