-
psnet.ahrq.gov/node/42913/psn-pdf
January 29, 2014 - enhance their usefulness, including prioritizing and examining incidents to identify
which events occur
-
psnet.ahrq.gov/node/34779/psn-pdf
December 21, 2014 - They
conclude that both approaches should occur continuously, with the statistical approach used only
-
hcup-us.ahrq.gov/reports/infographics/AdverseDrugEventsInfographic.pdf
February 12, 2015 - Hospitals
Adverse drug events (ADEs) are the most common nonsurgical adverse events that occur in hospitals
-
psnet.ahrq.gov/node/44474/psn-pdf
September 24, 2016 - interruptions-wild-development-sociotechnical-systems-model-interruptions-
emergency
Interruptions are a known safety hazard that occur
-
psnet.ahrq.gov/node/44106/psn-pdf
September 12, 2016 - psnet.ahrq.gov/issue/planning-mr-suite-what-can-be-done-enhance-safety
Although rare, adverse events still occur
-
psnet.ahrq.gov/node/43945/psn-pdf
September 09, 2015 - hospital-and-procedure-incidence-pediatric-retained-surgical-items
Retained surgical items are classified as never events, but they continue to occur
-
psnet.ahrq.gov/node/43811/psn-pdf
July 18, 2018 - annual-benchmarking-report-malpractice-risks-diagnostic-process
This analysis of more than 4700 diagnosis-related malpractice claims found that most errors occur
-
psnet.ahrq.gov/node/44099/psn-pdf
November 06, 2015 - sorry-i-meant-patients-left-side-impact-distraction-left-right-discrimination
Wrong-side procedures still occur
-
psnet.ahrq.gov/node/47473/psn-pdf
December 05, 2018 - offers recommendations for clinicians to
demonstrate their concern and improve practice when problems occur
-
psnet.ahrq.gov/node/35127/psn-pdf
February 24, 2011 - medical errors should produce greater insight through increased acknowledgment of errors
when they occur
-
psnet.ahrq.gov/node/44585/psn-pdf
November 04, 2015 - to use at least two patient identifiers when obtaining an
imaging study, wrong-patient events still occur
-
psnet.ahrq.gov/node/45673/psn-pdf
December 07, 2016 - publication explores how mistakes such as selecting
the wrong drug from an ordering pick list can occur
-
psnet.ahrq.gov/node/42134/psn-pdf
July 16, 2013 - developing-and-pilot-testing-practical-measures-preanalytic-surgical-specimen-
identification
Surgical specimen identification errors occur
-
psnet.ahrq.gov/node/43596/psn-pdf
December 19, 2014 - the anesthesiology field has long been involved in the patient safety movement, errors continue to
occur
-
psnet.ahrq.gov/node/46274/psn-pdf
September 13, 2017 - adoption of the Universal Protocol and widespread prevention efforts, wrong-site surgeries
continue to occur
-
psnet.ahrq.gov/node/38930/psn-pdf
January 04, 2010 - clinical consequences in Australia,
estimating that nearly 200,000 medication-related hospital admissions occur
-
psnet.ahrq.gov/node/34990/psn-pdf
June 22, 2009 - The authors determined that ADRs occur as frequently in
pediatric patients as in adult patients and
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/four-moments/poster-one-option.pdf
November 01, 2019 - Four Moments Poster
AHRQ Pub. No. 17(20)-0028-EF
November 2019
Moment 1 occurs at the time initiation of antibiotic therapy is considered:
Ask, “Does my patient have an infection that requires antibiotics?”
occurs when the dec…
-
psnet.ahrq.gov/node/40000/psn-pdf
November 10, 2017 - measurable entity fails to
account for the complex social and organizational dynamics that allow errors to occur
-
psnet.ahrq.gov/node/42779/psn-pdf
January 29, 2014 - governing-patient-safety-lessons-learned-mixed-methods-evaluation-
implementing-ward-level
Unsafe medication practices and errors occur