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psnet.ahrq.gov/node/36200/psn-pdf
February 15, 2011 - Choosing your words carefully: how physicians would
disclose harmful medical errors to patients.
February 15, 2011
Gallagher TH, Garbutt J, Waterman AD, et al. Choosing your words carefully: how physicians would
disclose harmful medical errors to patients. Arch Intern Med. 2006;166(15):1585-1593.
https://psnet.ahr…
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psnet.ahrq.gov/node/41522/psn-pdf
December 02, 2014 - Tenfold medication errors: 5 years' experience at a
university-affiliated pediatric hospital.
December 2, 2014
Doherty C, Donnell CM. Tenfold medication errors: 5 years' experience at a university-affiliated pediatric
hospital. Pediatrics. 2012;129(5):916-924. doi:10.1542/peds.2011-2526.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/46302/psn-pdf
December 22, 2017 - Non–health care facility medication errors resulting in
serious medical outcomes.
December 22, 2017
Hodges NL, Spiller HA, Casavant MJ, et al. Non-health care facility medication errors resulting in serious
medical outcomes. Clin Toxicol (Phila). 2018;56(1):43-50. doi:10.1080/15563650.2017.1337908.
https://psnet.a…
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psnet.ahrq.gov/node/50949/psn-pdf
February 26, 2020 - Medical
testing error occurs most frequently during the pre-analytic phase.
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psnet.ahrq.gov/issue/prevalence-and-economic-burden-medication-errors-nhs-england
September 11, 2018 - Book/Report
Prevalence and Economic Burden of Medication Errors in the NHS England.
Citation Text:
Prevalence and Economic Burden of Medication Errors in the NHS England. Elliott RA, Camacho E, Campbell F, et al. Policy Research Unit in Economic Evaluation of Health and Care Intervention…
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psnet.ahrq.gov/issue/multimodal-system-designed-reduce-errors-recording-and-administration-drugs-anaesthesia
September 26, 2012 - Study
Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation.
Citation Text:
Merry A, Webster CS, Hannam J, et al. Multimodal system designed to reduce errors in recording and administration of drugs…
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psnet.ahrq.gov/web-mm/one-ace-too-many
June 21, 2016 - Succinylcholine Trimethoprim Amiloride-like effect on distal tubule; occurs
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psnet.ahrq.gov/node/49854/psn-pdf
February 01, 2019 - psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
The care of hospitalized patients occurs
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psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - Medication Overdose
Citation Text:
Kaushal R. Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/web-mm/which-end-which
February 09, 2011 - Which End Is Which?
Citation Text:
Campbell AR. Which End Is Which?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/node/39730/psn-pdf
December 21, 2014 - Surgical case listing accuracy: failure analysis at a high-
volume academic medical center.
December 21, 2014
Cima RR, Hale C, Kollengode A, et al. Surgical case listing accuracy: failure analysis at a high-volume
academic medical center. Arch Surg. 2010;145(7):641-6. doi:10.1001/archsurg.2010.112.
https://psnet.a…
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psnet.ahrq.gov/node/46587/psn-pdf
January 23, 2019 - Association between workarounds and medication
administration errors in bar-code-assisted medication
administration in hospitals.
January 23, 2019
van der Veen W, van den Bemt PMLA, Wouters H, et al. Association between workarounds and medication
administration errors in bar-code-assisted medication administration…
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psnet.ahrq.gov/web-mm/empty-bag
June 01, 2018 - This occurs when there is a need to change infusions without interrupting the flow. … NB: It is typical for the primary infusion to be paused while the piggyback/secondary infusion occurs
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psnet.ahrq.gov/node/49774/psn-pdf
November 01, 2016 - Concealed hemorrhage
most commonly occurs during a ruptured ectopic pregnancy or following a cesarean … estimated to
complicate 2%–6% of all births.(5,13,14) Severe hemorrhage requiring blood transfusion occurs
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psnet.ahrq.gov/node/49420/psn-pdf
October 01, 2003 - To LP or Not LP
October 1, 2003
Landrigan CP. To LP or Not LP. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/lp-or-not-lp
The Case
A 4-month-old male infant was seen in the office setting of a large multisite practice. He presented with
fever and irritability without an obvious source. He was referred to …
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psnet.ahrq.gov/node/49387/psn-pdf
February 01, 2003 - Patient Mix-Up
February 1, 2003
Shojania KG. Patient Mix-Up. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/patient-mix
The Case
Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general
medical service at an academic medical center. Overnight, another man wit…
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psnet.ahrq.gov/node/33628/psn-pdf
February 01, 2006 - narcissism as it pertains to patient safety the inability to recognize or
acknowledge an error when it occurs
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psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - Wrong-level exposure occurs when a level other than the intended level of
surgery is exposed; however
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psnet.ahrq.gov/node/33871/psn-pdf
December 22, 2018 - the
improvement work on respectful maternity care has focused on other countries, disrespectful care occurs
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psnet.ahrq.gov/node/33755/psn-pdf
September 01, 2013 - Culture change inevitably occurs slowly, through cycles of action and interpretation.(8)
Problem solving