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psnet.ahrq.gov/issue/do-not-let-depo-medications-be-depot-mistakes
March 15, 2022 - June 10, 2018
Proper positioning of pharmacy label on Hospira PCA vials will avoid interference
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psnet.ahrq.gov/issue/experts-offer-smart-tips-smart-pumps
May 20, 2020 - May 2, 2018
Proper positioning of pharmacy label on Hospira PCA vials will avoid interference
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - The Commentary This error involves a system failure in the proper identification, documentation, and … quite different from the corresponding trade-name products; in such cases, expert review can facilitate proper
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psnet.ahrq.gov/issue/decreasing-clinically-significant-adverse-events-using-feedback-emergency-physicians
January 21, 2015 - The authors conclude that, with proper feedback to physicians and resident education, such a program
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psnet.ahrq.gov/issue/interrogating-and-uprooting-systemic-racism-emergency-department
March 05, 2025 - 2024
WebM&M Cases
A Laceration that Needed a Proper
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psnet.ahrq.gov/issue/temporarily-holding-medication-orders-safely-order-prevent-patient-harm
March 14, 2023 - May 3, 2023
Patient death tied to lack of proper escalation process for barcode scanning
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psnet.ahrq.gov/issue/use-tall-man-letters-gaining-wide-acceptance
May 02, 2018 - May 5, 2018
Proper positioning of pharmacy label on Hospira PCA vials will avoid interference
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psnet.ahrq.gov/issue/benefits-and-risks-including-patients-rca-teams
May 02, 2018 - May 5, 2018
Proper positioning of pharmacy label on Hospira PCA vials will avoid interference
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psnet.ahrq.gov/issue/safe-practice-environment-chapter-proposed-usp
May 02, 2018 - May 5, 2018
Proper positioning of pharmacy label on Hospira PCA vials will avoid interference
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psnet.ahrq.gov/issue/dont-underestimate-impact-change-risk-potential
May 02, 2018 - May 5, 2018
Proper positioning of pharmacy label on Hospira PCA vials will avoid interference
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psnet.ahrq.gov/issue/evaluation-nurse-interaction-bar-code-medication-administration-technology-work-environment
April 15, 2020 - June 16, 2019
Proper positioning of pharmacy label on Hospira PCA vials will avoid interference
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psnet.ahrq.gov/issue/use-standard-design-medication-room-promote-medication-safety-organizational-implications
July 27, 2022 - November 23, 2011
Patient safety begins with proper planning: a quantitative method to
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psnet.ahrq.gov/issue/ismps-second-quarterwatch-report-shows-sharp-increase-reports-serious-adverse-drug-events
June 10, 2018 - May 5, 2018
Proper positioning of pharmacy label on Hospira PCA vials will avoid interference
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psnet.ahrq.gov/issue/fda-advise-err-prevent-dangerous-drug-device-interaction-causing-falsely-elevated-glucose
May 02, 2018 - May 5, 2018
Proper positioning of pharmacy label on Hospira PCA vials will avoid interference
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psnet.ahrq.gov/issue/how-hospital-design-saves-lives
July 06, 2011 - August 29, 2007
Proper positioning of pharmacy label on Hospira PCA vials will avoid
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psnet.ahrq.gov/issue/deficits-communication-and-information-transfer-between-hospital-based-and-primary-care
January 25, 2017 - summary) generally was not available in a timely fashion and often contained inadequate information for proper
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psnet.ahrq.gov/issue/nurses-shift-length-and-overtime-working-12-european-countries-association-perceived-quality
August 20, 2018 - A past AHRQ WebM&M interview with Barbara Blakeney discussed the importance of proper nursing staffing
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psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - and Administration (1)
• Use of standardized pain order sets can improve opioid safety
through:
– Proper … lettering on
pharmacy-applied labels
• Dual signature verification with double-
check by 2 RNs to verify proper … availability of oxygen and naloxone
• ETCO2 use (capnography)
• Teach patient and family about the proper
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psnet.ahrq.gov/web-mm/result-stopped-here
December 01, 2006 - Proper handling of the result would have led to proper treatment and prevented patient harm. … The timing increased the likelihood of error, since proper handling of the laboratory result required
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psnet.ahrq.gov/issue/ismp-gap-analysis-tool-gat-safe-iv-push-medication-practices
June 13, 2018 - December 27, 2018
Proper positioning of pharmacy label on Hospira PCA vials will avoid