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psnet.ahrq.gov/node/61082/psn-pdf
July 23, 2020 - , care has become more labor-intensive, exacerbating shortages and making
it difficult to maintain proper … valuable and essential role they play, which may include offering staff
hazard pay.16 Additionally, as proper
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psnet.ahrq.gov/issue/paralyzed-mistakes-reassess-safety-neuromuscular-blockers-your-facility
July 27, 2016 - Newspaper/Magazine Article
Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility.
Citation Text:
Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. ISMP Medication Safety Alert! Acute Care Edition. June 16, 2016;21:1-6. …
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psnet.ahrq.gov/issue/speaking-about-patient-safety-requires-observant-questioner-and-high-index-suspicion
June 10, 2018 - Newspaper/Magazine Article
Speaking up about patient safety requires an observant questioner and a high index of suspicion.
Citation Text:
Speaking up about patient safety requires an observant questioner and a high index of suspicion. ISMP Medication Safety Alert! Acute Care Edition. Oc…
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psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update
March 23, 2012 - Book/Report
Classic
Serious Reportable Events in Healthcare—2011 Update.
Citation Text:
Serious Reportable Events in Healthcare—2011 Update. Washington DC: National Quality Forum; December 2011.
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psnet.ahrq.gov/issue/another-round-blame-game-paralyzing-criminal-indictment-recklessly-overrides-just-culture
May 02, 2018 - Newspaper/Magazine Article
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.
Citation Text:
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture. ISMP Medication Safety Alert! …
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psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
May 01, 2017 - part of the pre-procedure patient evaluation.( 9 ) Some institutions utilize guidelines toward the proper … complications requires careful patient selection, adherence to standard technical safety procedures, and proper
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psnet.ahrq.gov/web-mm/environmental-safety-or
May 19, 2015 - prevention of healthcare-associated infections.( 9 ) An inverse relationship has been demonstrated between proper … this important intervention typically hovers around 40%.( 18 ) This may be due to the many barriers to proper
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psnet.ahrq.gov/web-mm/departure-central-line-ritual
October 13, 2018 - verify appropriate placement of the catheter via ultrasound, as with the immediate verification of proper … placement of an endotracheal tube, multiple modalities and techniques should be employed to confirm proper
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psnet.ahrq.gov/issue/underreporting-robotic-surgery-complications
November 21, 2017 - Study
Underreporting of robotic surgery complications.
Citation Text:
Cooper M, Ibrahim AM, Lyu H, et al. Underreporting of robotic surgery complications. J Healthc Qual. 2015;37(2):133-8. doi:10.1111/jhq.12036.
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psnet.ahrq.gov/issue/usability-study-two-common-defibrillators-reveals-hazards
June 16, 2009 - Study
Usability study of two common defibrillators reveals hazards.
Citation Text:
Fairbanks RJ, Caplan SH, Bishop PA, et al. Usability Study of Two Common Defibrillators Reveals Hazards. Ann Emerg Med. 2007;50(4):424-432. doi:10.1016/j.annemergmed.2007.03.029.
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psnet.ahrq.gov/node/49508/psn-pdf
January 01, 2007 - The pharmacist attempted to demonstrate proper
dosing and administration using the medication dropper … At the time of discharge from the hospital, the
nurse counseled the parents on proper dosing through
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psnet.ahrq.gov/node/850362/psn-pdf
June 14, 2023 - Take-Home points
Home medications brought into the hospital for use require vigilance to ensure proper
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psnet.ahrq.gov/node/49540/psn-pdf
August 21, 2007 - Resuscitation Errors: A Shocking Problem
August 21, 2007
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
Case Objectives
Appreciate that delays in defibrillation can have significant negative effects on sur…
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - positives and false negatives, especially if measurements are not obtained at an ideal anatomic location or proper … 2022
WebM&M Cases
A Laceration that Needed a Proper … Related Resources
WebM&M Cases
A Laceration that Needed a Proper
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psnet.ahrq.gov/issue/classification-health-information-technology-safety-events-pediatric-tertiary-care-hospital
May 20, 2019 - Study
Classification of health information technology safety events in a pediatric tertiary care hospital.
Citation Text:
Khan A, Karavite DJ, Muthu N, et al. Classification of health information technology safety events in a pediatric tertiary care hospital. J Patient Saf. 2023;19(4):25…
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - To ensure proper patient identification, the hospital had implemented a policy requiring a registered … from weakest to strongest, are:
Weak : Retrain the phlebotomist and nurse regarding following the proper
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psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
November 16, 2022 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures
Citation Text:
Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/issue/lessons-learned-implementation-computerized-provider-order-entry-5-community-hospitals
December 31, 2014 - Study
Lessons learned from implementation of computerized provider order entry in 5 community hospitals: a qualitative study.
Citation Text:
Simon SR, Keohane CA, Amato MG, et al. Lessons learned from implementation of computerized provider order entry in 5 community hospitals: a quali…
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psnet.ahrq.gov/issue/compliance-who-surgical-safety-checklist-deviations-and-possible-improvements
September 29, 2017 - Study
Compliance with the WHO Surgical Safety Checklist: deviations and possible improvements.
Citation Text:
Rydenfält C, Johansson G, Odenrick P, et al. Compliance with the WHO Surgical Safety Checklist: deviations and possible improvements. Int J Qual Health Care. 2013;25(2):182-187. …
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psnet.ahrq.gov/issue/survey-evaluation-national-patient-safety-agencys-root-cause-analysis-training-programme
March 11, 2009 - Study
Survey evaluation of the National Patient Safety Agency’s Root Cause Analysis training programme in England and Wales: knowledge, beliefs and reported practices.
Citation Text:
Wallace LM, Spurgeon P, Adams S, et al. Survey evaluation of the National Patient Safety Agency's Root …