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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
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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/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.
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psnet.ahrq.gov/node/40844/psn-pdf
January 04, 2012 - intensive-care-unit-readmissions-us-hospitals-patient-characteristics-risk-
factors-and
In this nationwide sample
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psnet.ahrq.gov/node/38416/psn-pdf
February 18, 2009 - search-procedures
Most errors in laboratory medicine occur in the preanalytical phase, that is, before the sample
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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
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psnet.ahrq.gov/node/43995/psn-pdf
August 02, 2015 - real-time did
not have adverse effects, it did not appreciably improve patient safety in this modest sample
-
psnet.ahrq.gov/node/47408/psn-pdf
September 19, 2018 - This report recommends best
practices, test case criteria, and sample test cases to help developers
-
psnet.ahrq.gov/node/44567/psn-pdf
October 14, 2015 - misery-doctors-first-days
https://psnet.ahrq.gov/issue/july-effect-analysis-never-events-nationwide-inpatient-sample
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psnet.ahrq.gov/node/837500/psn-pdf
June 22, 2022 - Based on a sample of over 46,000 Medicare patients with pneumonia discharged between
July 2010 and December
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psnet.ahrq.gov/node/60933/psn-pdf
September 23, 2020 - Serum specimens were collected from a convenience sample
of 3,248 frontline personnel between April
-
psnet.ahrq.gov/node/838251/psn-pdf
October 05, 2022 - hospital-based-transfusion-error-tracking-2005-2010-identifying-key-errors-threatening
https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample
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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
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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
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - However, due to delays in receiving those results, another sample was tested two days later with a newly … developed in-house test and a third sample was sent to the state public health laboratory. … positive test run on the in-house platform was due to cross-contamination from a neighboring positive sample … A follow-up test conducted on a remnant sample from the in-house assay, one week later, confirmed that
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psnet.ahrq.gov/node/44431/psn-pdf
October 21, 2015 - use-human-factors-classification-framework-identify-causal-factors-medication-
and-medical
Researchers examined a random sample
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psnet.ahrq.gov/node/44675/psn-pdf
July 05, 2016 - july-effect-impact-academic-year-end-changeover-patient-outcomes-systematic-review
https://psnet.ahrq.gov/issue/july-effect-analysis-never-events-nationwide-inpatient-sample
-
psnet.ahrq.gov/node/43385/psn-pdf
August 06, 2014 - causation model to determine latent causes of medication errors requiring
hospital admission in a sample
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psnet.ahrq.gov/node/43568/psn-pdf
April 25, 2016 - Despite this
recommendation, this convenience sample of 34 children's hospitals across the United States
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psnet.ahrq.gov/node/44936/psn-pdf
May 09, 2017 - Surescripts electronic pharmacy claims data to prevent
admission medication history errors among a sample