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psnet.ahrq.gov/issue/using-ismp-medication-safety-self-assessment-improve-medication-use-processes
January 05, 2017 - June 13, 2011
Sample to sample carryover: a source of analytical laboratory error and
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psnet.ahrq.gov/issue/quality-improvement-decrease-specimen-mislabeling-transfusion-medicine
September 11, 2024 - September 29, 2021
Electronic patient identification for sample labeling reduces wrong … December 24, 2008
WebM&M Cases
Right Patient, Wrong Sample
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psnet.ahrq.gov/web-mm/hemolysis-holdup
July 03, 2016 - However, the laboratory noted that the patient's blood sample was hemolyzed, which can spuriously increase … Effective practices to reduce blood sample hemolysis in emergency departments. [Available at] 7. … Effectiveness of practices to reduce blood sample hemolysis in EDs: a laboratory medicine best practices
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psnet.ahrq.gov/issue/preanalytical-errors-primary-healthcare-questionnaire-study-information-search-procedures
July 07, 2010 - Most errors in laboratory medicine occur in the preanalytical phase, that is, before the sample reaches
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psnet.ahrq.gov/node/38418/psn-pdf
February 18, 2009 - Using snowball sampling method with nurses to
understand medication administration errors.
February 18, 2009
Sheu S-J, Wei I-L, Chen C-H, et al. Using snowball sampling method with nurses to understand medication
administration errors. J Clin Nurs. 2009;18(4):559-69. doi:10.1111/j.1365-2702.2007.02048.x.
https://p…
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psnet.ahrq.gov/node/43080/psn-pdf
March 26, 2014 - psnet.ahrq.gov/issue/reducing-adverse-events-blood-transfusion
https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample
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psnet.ahrq.gov/node/42838/psn-pdf
January 08, 2014 - Management of arterial lines and blood sampling in
intensive care: a threat to patient safety.
January 8, 2014
Leslie RA, Gouldson S, Habib N, et al. Management of arterial lines and blood sampling in intensive care: a
threat to patient safety. Anaesthesia. 2013;68(11). doi:10.1111/anae.12389.
https://psnet.ahrq.g…
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psnet.ahrq.gov/issue/transfusion-safety-nature-and-outcomes-errors-patient-registration
December 16, 2020 - A national random sample survey about "truth-telling practices" in the perioperative setting in the United … June 14, 2019
Electronic patient identification for sample labeling reduces wrong blood
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psnet.ahrq.gov/issue/emergency-departments-are-higher-risk-locations-wrong-blood-tube-errors
November 17, 2021 - February 10, 2021
Electronic patient identification for sample labeling reduces wrong … Transfusion Event
January 29, 2020
Electronic patient identification for sample
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psnet.ahrq.gov/issue/path-safety-benefits-2005-patient-safety-and-quality-improvement-act
June 03, 2015 - July 18, 2016
Sample to sample carryover: a source of analytical laboratory error and
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psnet.ahrq.gov/issue/ismp-medication-safety-alertr-nurse-advise-err
January 26, 2023 - Sample articles are available at the site.
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psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - Right Patient, Wrong Sample
December 1, 2006
Astion ML. Right Patient, Wrong Sample. … https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample
The Case
A 54-year-old man was admitted to … The sample
was sent to the laboratory for analysis. … morning, a laboratory technician noticed a large and surprising change (compared to the
previous day’s sample … classified as preanalytic, analytic, or postanalytic (see
https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample
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psnet.ahrq.gov/node/34010/psn-pdf
June 20, 2019 - Sample articles are available at
the site.
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psnet.ahrq.gov/issue/using-snowball-sampling-method-nurses-understand-medication-administration-errors
August 02, 2011 - Study
Using snowball sampling method with nurses to understand medication administration errors.
Citation Text:
Sheu S-J, Wei I-L, Chen C-H, et al. Using snowball sampling method with nurses to understand medication administration errors. J Clin Nurs. 2009;18(4):559-69. doi:10.1111/j.1…
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psnet.ahrq.gov/issue/using-preprinted-medication-order-forms-improve-safety-investigational-drug-use
April 24, 2024 - authors advise on how to minimize medication errors when dispensing investigational drugs and provide a sample
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psnet.ahrq.gov/issue/take-charge-your-hospital-stay-avoid-medical-mistakes
April 08, 2020 - Sample tips are to obtain copies of important records and carefully consider timing when scheduling
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psnet.ahrq.gov/node/866814/psn-pdf
September 25, 2024 - This study used the large language model (LLM) ChatGPT-3.5
in a secure environment to label a sample
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psnet.ahrq.gov/node/866955/psn-pdf
October 16, 2024 - In this random
sample of patients hospitalized in general medicine, approximately 1 in 14 patients experienced
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psnet.ahrq.gov/node/866567/psn-pdf
August 21, 2024 - It provides a
sample structure for HRO huddles at the unit level.
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psnet.ahrq.gov/node/34719/psn-pdf
December 23, 2008 - Learning from samples of one or fewer.
December 23, 2008
March JG, Sproull LS, Tamuz M. Org Sci.1991;2:1-13. (reprinted in: Qual Saf Health Care 2003;12:465-
472.)
https://psnet.ahrq.gov/issue/learning-samples-one-or-fewer
Organizations learn from experience. However, learning from rare events is challenging becau…