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psnet.ahrq.gov/node/41535/psn-pdf
December 31, 2014 - Understanding and preventing wrong-patient electronic
orders: a randomized controlled trial.
December 31, 2014
Adelman JS, Kalkut GE, Schechter CB, et al. Understanding and preventing wrong-patient electronic
orders: a randomized controlled trial. J Am Med Inform Assoc. 2013;20(2):305-310. doi:10.1136/amiajnl-
201…
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psnet.ahrq.gov/node/44671/psn-pdf
September 20, 2016 - Primary care physicians' willingness to disclose oncology
errors involving multiple providers to patients.
September 20, 2016
Mazor KM, Roblin DW, Greene SM, et al. Primary care physicians' willingness to disclose oncology errors
involving multiple providers to patients. BMJ Qual Saf. 2016;25(10):787-95. doi:10.113…
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psnet.ahrq.gov/glossary/handoffs-and-handovers
September 13, 2021 - Handoffs and Handovers
September 13, 2021
Anonymous (not verified)
See Primer . The process when one health care professional updates another on the status of one or more patients for the purpose of taking over their care. Typical examples involve a physician who has been on call overnight telling an incoming …
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psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
November 25, 2020 - EMS Perils from Hospital Overcrowding
Citation Text:
Brown S, Rose JS, Barnes DK. EMS Perils from Hospital Overcrowding. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - Falling Through the Crack (in the Bedrails)
May 1, 2016
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
Case Objectives
Review the epidemiology of patient falls and associated injuries in the hospital set…
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psnet.ahrq.gov/issue/multimodal-system-designed-reduce-errors-recording-and-administration-drugs-anaesthesia
September 26, 2012 - March 23, 2011
Medication errors occurring with the use of bar-code administration technology
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
December 01, 2004 - Adverse drug events occurring following hospital discharge [abstract]. … Adverse drug events occurring following hospital discharge [abstract].
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psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
October 24, 2018 - April 12, 2019
Root cause analyses of reported adverse events occurring during gastrointestinal
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psnet.ahrq.gov/issue/root-cause-analysis-serious-adverse-events-among-older-patients-veterans-health
August 02, 2015 - April 12, 2019
Root cause analyses of reported adverse events occurring during gastrointestinal
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psnet.ahrq.gov/issue/supratherapeutic-dosing-acetaminophen-among-hospitalized-patients
February 14, 2017 - October 30, 2010
Medication errors occurring with the use of bar-code administration
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psnet.ahrq.gov/issue/improving-health-care-quality-and-patient-safety-through-peer-peer-assessment-demonstration
March 14, 2018 - September 29, 2021
Systematic evaluation of errors occurring during the preparation of
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psnet.ahrq.gov/issue/inadequacies-physical-examination-cause-medical-errors-and-adverse-events-collection
June 01, 1989 - April 22, 2015
Baccalaureate nursing students' accounts of medical mistakes occurring
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psnet.ahrq.gov/issue/can-asking-emergency-physicians-whether-or-not-they-would-have-done-something-differently
July 01, 2016 - January 26, 2022
Analysis of risk factors for patient safety events occurring in the
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psnet.ahrq.gov/issue/missed-serious-neurologic-conditions-emergency-department-patients-discharged-nonspecific
April 08, 2018 - March 19, 2019
Analysis of risk factors for patient safety events occurring in the emergency
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psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - The Commentary
Background Errors in laboratory services encompass a number of problems occurring outside … physicians often attribute to errors inside the laboratory, are actually the result
of preanalytic problems occurring … Specific Errors in This Case The particular error in this case is a mislabeling error occurring outside
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - warrants close assessment and aggressive management by nursing staff to prevent serious breakdown from occurring … constitute nearly 10% of Medicare admissions to acute care, with nearly 40% of these hospitalizations occurring … taking high risk medications such as anticoagulants are monitored daily to assure no adverse events are occurring
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psnet.ahrq.gov/node/49650/psn-pdf
March 01, 2012 - The most recent analysis described 46
deaths and 263 procedure-related complications occurring from … references
https://psnet.ahrq.gov//#references
Quality improvement strategies to prevent these events from occurring
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psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - In a recent study of adverse events occurring on
mental health units in the Veterans Health Administration … Adverse events occurring on VHA mental health units. Gen
Hosp Psychiatry. 2018;50:63-68.
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psnet.ahrq.gov/node/33687/psn-pdf
August 01, 2009 - downside of first-order problem solving is lack of
communication, which hinders real improvement from occurring … Even this meager form of second-order problem solving was rare,
occurring in only 7% of the situations
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - The Commentary
Background Errors in laboratory services encompass a number of problems occurring outside … often attribute to errors inside the laboratory, are actually the result of preanalytic problems occurring … Specific Errors in This Case The particular error in this case is a mislabeling error occurring outside