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psnet.ahrq.gov/node/49433/psn-pdf
June 23, 2021 - Environmental Safety in the OR
February 1, 2004
Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/environmental-safety-or
The Case
The infection control department of a hospital noticed a marked increase in the rates of post-operative
sternal wound inf…
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/issue/reporting-patient-safety-incidents-first-experiences-chiropractic-reporting-and-learning
September 11, 2024 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
-
psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - Michael Astion, MD, PhD Associate Professor and Director of Reference Laboratory Services Editor-in- … Taxonomy of Laboratory Errors in Use by a Number of Laboratories with
Minor Modifications (Adapted from Reference
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psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - Adverse Event During Intrahospital Transport
February 1, 2019
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
The Case
A 4-year-old boy underwent surgery under general anesthesia for correction o…
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psnet.ahrq.gov/node/49619/psn-pdf
February 01, 2011 - While echocardiography is the non-invasive reference standard for the detection of cardiac
tamponade
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psnet.ahrq.gov/node/49835/psn-pdf
January 01, 2020 - Don't Pick the PICC
July 1, 2018
McGill RL. Don't Pick the PICC. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/dont-pick-picc
The Case
A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy;
glaucoma; and stage IV chronic kidney disease was admitted to the hospita…
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - The American Academy of Pediatrics (AAP) policy
statement defines "exclusive breastfeeding [as] the reference
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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - Usability testing can aid in the improved
design of pump labels and other cognitive aids (eg, quick-reference
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psnet.ahrq.gov/issue/fast-does-not-imply-flawed-analyzing-emergency-physician-productivity-and-medical-errors
January 25, 2023 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
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psnet.ahrq.gov/issue/prevalence-errors-anaphylaxis-kids-peak-multicenter-simulation-based-study
June 15, 2022 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
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psnet.ahrq.gov/issue/simulation-tool-improve-safety-pre-hospital-anaesthesia-pilot-study
October 19, 2022 - paramedics during pediatric patient simulations after implementation of a state-wide pediatric drug dosing reference
-
psnet.ahrq.gov/node/49870/psn-pdf
August 10, 2019 - Anemia and Delayed Colon Cancer Diagnosis
August 10, 2019
Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
Case Objectives
Describe the initial evaluation for iron deficiency anemia in elderly adults…
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psnet.ahrq.gov/node/49679/psn-pdf
March 01, 2013 - withdrawing the syringe and clamping the catheter if indicated, are available for
instruction and reference
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psnet.ahrq.gov/node/49856/psn-pdf
March 01, 2019 - Premature Extubation
March 1, 2019
Sagana R, Hyzy RC. Premature Extubation. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/premature-extubation
The Case
A 73-year-old woman with a history of carotid artery stenosis was admitted for an elective carotid
endarterectomy. The procedure was initially thought to …
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psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - Strategies to reduce medication errors with reference to older
adults.
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psnet.ahrq.gov/node/49866/psn-pdf
June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the
Operating Room
June 1, 2019
Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
The Case
A 43-year-old woman was admi…
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psnet.ahrq.gov/glossary/latent-error-or-latent-condition
September 13, 2021 - Latent Error (or Latent Condition)
September 13, 2021
Anonymous (not verified)
The terms active and latent as applied to errors were coined by Reason . Latent errors (or latent conditions) refer to less apparent failures of organization or design that contributed to the occurrence of errors or allowed them…
-
psnet.ahrq.gov/node/49503/psn-pdf
February 01, 2006 - Laboratory studies showed an insulin
level of greater than 1500 micro-units/mL (upper end of the reference
-
psnet.ahrq.gov/node/49657/psn-pdf
July 01, 2012 - Not-So-Therapeutic Tap
July 1, 2012
Barsuk JH. Not-So-Therapeutic Tap. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
Case Objectives
Describe current issues with training clinicians to perform procedures.
Understand how simulation can be used to ensure trainees are competent in proc…