-
psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - She was referred to a surgeon for a biopsy, but there was confusion about whether the patient herself
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psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
April 04, 2018 - opioid therapy, should have been appropriately monitored, and should have been weaned off opioids or referred
-
psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd
February 26, 2025 - We had a really lovely example of that, in our US paper we referred to it as the personal touch for
-
psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
March 27, 2024 - care agent (sometimes also called surrogate, representative, decision-maker, or proxy; or erroneously referred
-
psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - These events may be
considered “near miss events” (often referred to as “miscounts”) and require valuable
-
psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
March 27, 2024 - The patient was taken to a community hospital-based urgent care clinic and then referred to the Emergency
-
psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - screening rates remain low throughout the United States. 15 In this case, the patient should have been referred
-
psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
July 23, 2024 - gestation), singleton (e.g., not twins), and vertex (not breech or transverse position)—collectively referred
-
psnet.ahrq.gov/node/836850/psn-pdf
March 31, 2022 - Control and
Prevention (CDC) published the Guideline for Prescribing Opioids for Chronic Pain (hereafter referred
-
psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - have followed
12
Background (2)
• This “perfect storm” of events--an error pattern commonly referred
-
psnet.ahrq.gov/node/837913/psn-pdf
August 31, 2022 - The
patient was taken to a community hospital-based urgent care clinic and then referred to the Emergency
-
psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - If the EHR is shared between the discharging and receiving facilities, the I-PASS tool can be easily referred
-
psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - the EHR is shared between the discharging and receiving facilities, the I-PASS tool can be
easily referred
-
psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - The nurse supervisor, frequently referred to as a "traffic-controller," is most often aware not only
-
psnet.ahrq.gov/node/867428/psn-pdf
December 18, 2024 - Nurses had to do these plans for the Joint Commission but never referred to them, so they
were not informing
-
psnet.ahrq.gov/node/33708/psn-pdf
March 01, 2011 - The written communication is sometimes referred
to as the transition record, like a transfer note, a
-
psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
October 01, 2016 - In other fields, the combination of a domain expert, a computer scientist, and a statistician is referred
-
psnet.ahrq.gov/node/33750/psn-pdf
May 01, 2013 - I recently referred to today's EHRs as
cutting edge 1995 technology.
-
psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - These events may be considered “near miss events” (often referred to as “miscounts”) and require valuable
-
psnet.ahrq.gov/node/837324/psn-pdf
July 08, 2022 - gestation), singleton (e.g., not twins), and vertex
(not breech or transverse position)—collectively referred