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psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
October 24, 2018 - Study
Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.
Citation Text:
Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health A…
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psnet.ahrq.gov/issue/medication-use-leading-emergency-department-visits-adverse-drug-events-older-adults
March 05, 2008 - Study
Classic
Medication use leading to emergency department visits for adverse drug events in older adults.
Citation Text:
Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for adverse drug events in older adults. A…
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - with immediate patient assessment.(5) They also may be more likely than busy bedside nurses to ensure
proper … With monitor watchers at a remote location, timely patient assessment, proper electrode
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/60856/psn-pdf
August 26, 2020 - Morning starts are recommended for high risk cases when possible, both to allow
proper marshalling of … inflammatory load, fluid volume shifts, exposure to anesthetic medications, heat
loss and infection risk.12 Proper
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psnet.ahrq.gov/node/49464/psn-pdf
December 27, 2020 - Careful inspection of all instruments and equipment
before use is critical and proper maintenance can
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psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - 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/primer/pharmacists-role-medication-safety
March 14, 2018 - medication information Educate patients and caregivers on safe and effective medication use Reviewing proper
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psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
March 01, 2015 - Had there been a proper handoff, the prehospital ECG would have been seen by ED providers at the time
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psnet.ahrq.gov/node/60611/psn-pdf
June 24, 2020 - Another key aspect of creating proper order sets is to link the correct set of orders to specific indications … This approach also makes it easier for physicians to write the prescription and to ensure proper
dose
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psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
May 16, 2022 - Take-Home points Home medications brought into the hospital for use require vigilance to ensure proper
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psnet.ahrq.gov/node/73998/psn-pdf
October 27, 2021 - Proper Intravenous Catheter Site Monitoring and Detection of Infiltration
Intravenous infiltration is
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psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
May 26, 2021 - As with any tool, proper use of the EHR depends on adequate training, practice, and attention. … can lead to medical errors and patient safety events if it is done without mindfulness, or without proper
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - laboratory specimens to improve data accuracy: Nursing and phlebotomy staff should be counseled on proper … 2022
WebM&M Cases
A Laceration that Needed a Proper
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psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
March 30, 2022 - The physicians who reviewed his medical record judged that proper diagnostic management might have discovered
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psnet.ahrq.gov/node/49569/psn-pdf
September 01, 2008 - Where's the Feeding Tube?
September 1, 2008
Metheny NA, Meert KL. Where's the Feeding Tube? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wheres-feeding-tube
The Case
A 13-year-old boy was involved in a motor vehicle collision and experienced a traumatic brain injury.
Because of the injuries, he was unabl…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
April 01, 2010 - Medication Errors
Access to patient-specific information
Access to drug information
Adequate communication
Proper
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psnet.ahrq.gov/node/49593/psn-pdf
October 01, 2009 - Proper placement of nasopharyngeal airway device, a soft plastic tube inserted into the nose
that extends
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psnet.ahrq.gov/node/49462/psn-pdf
October 01, 2004 - Lockouts prevent easy entrance to a
dangerous set of actions or a segment of software, without the proper
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psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
October 01, 2013 - Many health care facilities are beginning to experiment with newer technologies to ensure proper patient
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psnet.ahrq.gov/node/867475/psn-pdf
February 26, 2025 - on their adverse effects and associated risks.4 Education should also emphasize the
importance of proper