-
psnet.ahrq.gov/node/40863/psn-pdf
October 19, 2011 - family became involved with patient safety,
serving on an advisory council at the hospital where it occurred
-
psnet.ahrq.gov/node/37941/psn-pdf
July 30, 2008 - finding-blunders-thyroid-testing-experience-newborns
Inconsistent and possibly erroneous results of thyroid tests for newborns occurred
-
psnet.ahrq.gov/node/43405/psn-pdf
August 14, 2014 - psnet.ahrq.gov/issue/characteristics-associated-postdischarge-medication-errors
Postdischarge medication errors occurred
-
psnet.ahrq.gov/node/38403/psn-pdf
February 11, 2009 - psnet.ahrq.gov/issue/frequency-types-and-potential-clinical-significance-medication-dispensing-
errors
Errors occurred
-
psnet.ahrq.gov/node/41136/psn-pdf
February 15, 2012 - adverse-events-after-screening-and-follow-colonoscopy
This study of more than 45,000 colonoscopies found that 4.7 serious adverse events occurred
-
hcup-us.ahrq.gov/reports/infographics/double-mastectomy.pdf
February 01, 2016 - The rise in mastectomies
occurred despite breast cancer
rates remaining constant.
2005 2013
Sharp
-
psnet.ahrq.gov/node/851191/psn-pdf
July 05, 2023 - disclosing-medical-errors-prioritising-needs-patients-and-families
Numerous organizations promote communication with patients and families after harm has occurred
-
psnet.ahrq.gov/node/853066/psn-pdf
August 30, 2023 - Researchers found
that MOID occurred in 29% of emergency transfer cases and it was associated with higher
-
psnet.ahrq.gov/node/49425/psn-pdf
November 01, 2003 - On face value, it is almost impossible to imagine how this could have occurred. … In addition to exploring why the error occurred at the level of individuals at the
"sharp end," such … effectively, but involves interviewing
staff involved to identify care management problems and why each occurred … Although physicians disclosed the adverse event, they
often avoided stating that an error had occurred
-
psnet.ahrq.gov/node/864369/psn-pdf
March 13, 2024 - A physician-related medication error occurred in 12.5% of participants overall, with no
statistically
-
healthcare411.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - There is no evidence in these reports that any other type of patient safety concern
occurred. … In several instances, the exposure occurred because staff were not following PPE protocols, such as … In other cases, the exposure occurred with an asymptomatic
individual, and was later identified when … Additional near misses occurred when the wrong blood product (e.g.,
fresh frozen plasma versus COVID … PSOs generally provided data elements for the location in the facility where the event occurred and
-
cahps.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - There is no evidence in these reports that any other type of patient safety concern
occurred. … In several instances, the exposure occurred because staff were not following PPE protocols, such as … In other cases, the exposure occurred with an asymptomatic
individual, and was later identified when … Additional near misses occurred when the wrong blood product (e.g.,
fresh frozen plasma versus COVID … PSOs generally provided data elements for the location in the facility where the event occurred and
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - There is no evidence in these reports that any other type of patient safety concern
occurred. … In several instances, the exposure occurred because staff were not following PPE protocols, such as … In other cases, the exposure occurred with an asymptomatic
individual, and was later identified when … Additional near misses occurred when the wrong blood product (e.g.,
fresh frozen plasma versus COVID … PSOs generally provided data elements for the location in the facility where the event occurred and
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - There is no evidence in these reports that any other type of patient safety concern
occurred. … In several instances, the exposure occurred because staff were not following PPE protocols, such as … In other cases, the exposure occurred with an asymptomatic
individual, and was later identified when … Additional near misses occurred when the wrong blood product (e.g.,
fresh frozen plasma versus COVID … PSOs generally provided data elements for the location in the facility where the event occurred and
-
www.cahps.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - There is no evidence in these reports that any other type of patient safety concern
occurred. … In several instances, the exposure occurred because staff were not following PPE protocols, such as … In other cases, the exposure occurred with an asymptomatic
individual, and was later identified when … Additional near misses occurred when the wrong blood product (e.g.,
fresh frozen plasma versus COVID … PSOs generally provided data elements for the location in the facility where the event occurred and
-
www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - There is no evidence in these reports that any other type of patient safety concern
occurred. … In several instances, the exposure occurred because staff were not following PPE protocols, such as … In other cases, the exposure occurred with an asymptomatic
individual, and was later identified when … Additional near misses occurred when the wrong blood product (e.g.,
fresh frozen plasma versus COVID … PSOs generally provided data elements for the location in the facility where the event occurred and
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - There is no evidence in these reports that any other type of patient safety concern
occurred. … In several instances, the exposure occurred because staff were not following PPE protocols, such as … In other cases, the exposure occurred with an asymptomatic
individual, and was later identified when … Additional near misses occurred when the wrong blood product (e.g.,
fresh frozen plasma versus COVID … PSOs generally provided data elements for the location in the facility where the event occurred and
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - There is no evidence in these reports that any other type of patient safety concern
occurred. … In several instances, the exposure occurred because staff were not following PPE protocols, such as … In other cases, the exposure occurred with an asymptomatic
individual, and was later identified when … Additional near misses occurred when the wrong blood product (e.g.,
fresh frozen plasma versus COVID … PSOs generally provided data elements for the location in the facility where the event occurred and
-
www.cpsi.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - There is no evidence in these reports that any other type of patient safety concern
occurred. … In several instances, the exposure occurred because staff were not following PPE protocols, such as … In other cases, the exposure occurred with an asymptomatic
individual, and was later identified when … Additional near misses occurred when the wrong blood product (e.g.,
fresh frozen plasma versus COVID … PSOs generally provided data elements for the location in the facility where the event occurred and
-
ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - There is no evidence in these reports that any other type of patient safety concern
occurred. … In several instances, the exposure occurred because staff were not following PPE protocols, such as … In other cases, the exposure occurred with an asymptomatic
individual, and was later identified when … Additional near misses occurred when the wrong blood product (e.g.,
fresh frozen plasma versus COVID … PSOs generally provided data elements for the location in the facility where the event occurred and