-
psnet.ahrq.gov/issue/hamilton-father-misdiagnosed-lung-cancer-demands-answers
September 13, 2017 - The potential causes of the mistake include laboratory sample confusion and misinterpretation of
-
psnet.ahrq.gov/issue/ways-improve-electronic-health-record-safety
February 08, 2017 - This report recommends best practices , test case criteria, and sample test cases to help developers
-
psnet.ahrq.gov/issue/what-every-health-care-organization-should-know-about-sentinel-events
November 27, 2018 - The text includes a sample sentinel event root cause analysis form and a glossary.
-
psnet.ahrq.gov/issue/medication-reconciliation-physician-order-form
January 21, 2015 - discuss background on one hospital's development of a medication reconciliation form and provide a sample
-
psnet.ahrq.gov/issue/predictors-nursing-home-nurses-willingness-report-medication-near-misses
July 31, 2024 - Using a random sample of 500 nursing home nurses in one state, this study tested a proposed predictive
-
psnet.ahrq.gov/issue/patient-identification-error-among-prostate-needle-core-biopsy-specimens-are-we-ready-dna
March 12, 2025 - June 30, 2011
WebM&M Cases
Right Patient, Wrong Sample
-
psnet.ahrq.gov/node/35773/psn-pdf
March 15, 2006 - Quality's (AHRQ) patient safety indicators, the researchers
analyzed a nationwide hospital discharge sample
-
psnet.ahrq.gov/node/36950/psn-pdf
September 09, 2011 - The authors discuss integrating safety and quality education into daily clinical practice and provide sample
-
psnet.ahrq.gov/node/41467/psn-pdf
June 20, 2012 - improved medication reconciliation by more accurately identifying medication errors at
admission, in this sample
-
psnet.ahrq.gov/node/844536/psn-pdf
February 15, 2023 - In this sample of births from 2008-2011, racialized
economic segregation was associated with SMM for
-
psnet.ahrq.gov/node/73883/psn-pdf
September 29, 2021 - case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading-institutional
https://psnet.ahrq.gov/issue/electronic-patient-identification-sample-labeling-reduces-wrong-blood-tube-errors
-
psnet.ahrq.gov/node/48110/psn-pdf
August 14, 2019 - Although most of the
nurses in this convenience sample reported speaking up about safety issues, nearly
-
psnet.ahrq.gov/node/33591/psn-pdf
March 15, 2025 - Use of the trigger tool involves screening a
defined sample of medical records by two independent clinicians … used 5 teams of
reviewers (each of whom had at least 3 years of GTT experience) to review a random sample
-
psnet.ahrq.gov/node/35989/psn-pdf
September 17, 2010 - authors advise on how to minimize medication errors when dispensing investigational drugs and
provide a sample
-
psnet.ahrq.gov/node/43880/psn-pdf
February 04, 2015 - Helpful resources such as checklists, sample control plans, and review exercises are also
included.
-
psnet.ahrq.gov/issue/identifying-cross-contaminants-and-specimen-mix-ups-surgical-pathology
July 22, 2020 - February 13, 2008
WebM&M Cases
Right Patient, Wrong Sample
-
psnet.ahrq.gov/node/41356/psn-pdf
May 29, 2012 - https://psnet.ahrq.gov/primer/checklists
https://psnet.ahrq.gov/issue/inappropriate-medication-national-sample-us-elderly-patients-receiving-home-health-care
-
psnet.ahrq.gov/node/44296/psn-pdf
April 08, 2018 - clinic visits did not significantly reduce diagnostic errors compared to usual care, though a
larger sample
-
psnet.ahrq.gov/node/44279/psn-pdf
August 26, 2015 - A major limitation of this study is a
small sample size and very low survey response rate.
-
psnet.ahrq.gov/node/74162/psn-pdf
December 08, 2021 - Using
a sample of Medicare beneficiaries from 2015 to 2018, researchers assessed the impact of state