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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. 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 …
  4. 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. Copy Citation Format: Google Scholar BibTeX E…
  5. Psn-Pdf (pdf file)

    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…
  6. 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
  7. 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].
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. Psn-Pdf (pdf file)

    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
  16. 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
  17. Psn-Pdf (pdf file)

    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
  18. Psn-Pdf (pdf file)

    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.
  19. Psn-Pdf (pdf file)

    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
  20. 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

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