-
psnet.ahrq.gov/issue/just-culture-guide
July 18, 2018 - failure has been highlighted as key to improving patient safety, individual behaviors must also be recognized
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psnet.ahrq.gov/issue/hospitals-win-safety-award-simple-changes
September 06, 2006 - This article spotlights two Philadelphia hospitals recognized for their innovative medication safety
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psnet.ahrq.gov/issue/medical-detective-story-why-doctors-make-diagnostic-errors
October 23, 2018 - improving diagnosis, this newspaper article features an interview with Hardeep Singh , a nationally recognized
-
psnet.ahrq.gov/node/39422/psn-pdf
March 23, 2011 - The importance of strong organizational leadership in
improving safety was recognized by The Joint Commission
-
psnet.ahrq.gov/node/45538/psn-pdf
December 14, 2016 - liquid-medication-errors-and-dosing-tools-randomized-controlled-experiment
Misinterpretation of medication labels is a well-recognized
-
psnet.ahrq.gov/node/39402/psn-pdf
August 08, 2010 - This error has been recognized since vincristine was first used in the 1960s
and is now classified as
-
psnet.ahrq.gov/node/44648/psn-pdf
February 14, 2017 - rising-drug-allergy-alert-overrides-electronic-health-records-observational-
retrospective
Alert fatigue is recognized
-
psnet.ahrq.gov/node/37997/psn-pdf
June 16, 2011 - revealing-and-resolving-patient-safety-defects-impact-leadership-walkrounds-
frontline
Executive walk rounds are a recognized
-
psnet.ahrq.gov/node/35494/psn-pdf
May 27, 2011 - hospital-implementation-computerized-provider-order-entry-systems-results-
2003-leapfrog-group
The Leapfrog Group's widely recognized
-
psnet.ahrq.gov/node/42882/psn-pdf
November 23, 2016 - structuring-patient-and-family-involvement-medical-error-event-disclosure-and-
analysis
Patient engagement is increasingly recognized
-
psnet.ahrq.gov/node/42047/psn-pdf
March 18, 2013 - do-you-have-re-examine-reconsider-your-diagnosis-checklists-and-cardiac-
exam
Diagnostic errors are increasingly recognized
-
psnet.ahrq.gov/node/37776/psn-pdf
January 31, 2011 - /psnet.ahrq.gov/issue/barcoded-medication-administration-last-line-defense
Barcoding technology is recognized
-
psnet.ahrq.gov/node/45773/psn-pdf
January 11, 2017 - opioid-related-inpatient-stays-and-emergency-department-visits-state-2009-
2014
Opioids are known to be high-risk medications, and their misuse is an increasingly recognized
-
psnet.ahrq.gov/node/42789/psn-pdf
December 04, 2013 - development-just-culture-assessment-tool-measuring-perceptions-health-care-
professionals
The importance of safety culture in medicine is well recognized
-
psnet.ahrq.gov/node/40548/psn-pdf
March 23, 2012 - Given
the recognized limitations of the Beers criteria, the STOPP criteria likely represent a superior
-
psnet.ahrq.gov/node/46820/psn-pdf
August 20, 2018 - postsurgical-prescriptions-opioid-naive-patients-and-association-overdose-
and-misuse
Harm from opioids is a widely recognized
-
psnet.ahrq.gov/node/46948/psn-pdf
April 16, 2018 - issue/opioid-related-critical-care-resource-use-us-childrens-hospitals
Opioid-related harm is a widely recognized
-
psnet.ahrq.gov/node/60746/psn-pdf
July 29, 2020 - their evaluation, including a pelvic
examination and repeated pelvic ultrasound at the bedside, they recognized … The sonographer recognized that the ultrasound
examination was technically suboptimal due to obesity … Another potentially serious error is misreporting, such as the failure to report a recognized finding
-
psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
January 01, 2020 - response
16
Causes of Medication Error and Adverse Outcomes (3)
• The night nurse should have
– Recognized … when given for seizures, especially in a
petite women with no recent history of benzodiazepine use
– Recognized … night nurse did not consistently assess the
patient’s response to the medication, or they would have
recognized
-
psnet.ahrq.gov/issue/triggers-bundles-protocols-and-checklists-what-every-maternal-care-provider-needs-know
October 19, 2022 - Obstetric care is recognized as a high-risk activity both for the mother and the infant.