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psnet.ahrq.gov/node/43122/psn-pdf
April 08, 2018 - Missed diagnosis of stroke in the emergency department:
a cross-sectional analysis of a large population-based
sample.
April 8, 2018
Newman-Toker DE, Moy E, Valente E, et al. Missed diagnosis of stroke in the emergency department: a
cross-sectional analysis of a large population-based sample. Diagnosis (Berl). 201…
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psnet.ahrq.gov/node/34704/psn-pdf
December 24, 2008 - Negligent care and malpractice claiming behavior in Utah
and Colorado.
December 24, 2008
Studdert DM, Thomas EJ, Burstin HR, et al. Negligent care and malpractice claiming behavior in Utah and
Colorado. Med Care. 2000;38(3):250-60.
https://psnet.ahrq.gov/issue/negligent-care-and-malpractice-claiming-behavior-utah-…
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psnet.ahrq.gov/issue/2-year-study-patient-safety-competency-assessment-29-clinical-laboratories
December 14, 2016 - Study
A 2-year study of patient safety competency assessment in 29 clinical laboratories.
Citation Text:
Reed RC, Kim S, Farquharson K, et al. A 2-Year Study of Patient Safety Competency Assessment in 29 Clinical Laboratories. Am J Clin Pathol. 2008;129(6). doi:10.1309/bm8jje1auca408tq…
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psnet.ahrq.gov/node/44305/psn-pdf
January 22, 2016 - National incidence of medication error in surgical patients
before and after Accreditation Council for Graduate
Medical Education duty-hour reform.
January 22, 2016
Vadera S, Griffith SD, Rosenbaum BP, et al. National Incidence of Medication Error in Surgical Patients
Before and After Accreditation Council for Gra…
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psnet.ahrq.gov/issue/quality-improvement-decrease-specimen-mislabeling-transfusion-medicine
September 11, 2024 - Study
Quality improvement to decrease specimen mislabeling in transfusion medicine.
Citation Text:
Quillen K, Murphy K. Quality improvement to decrease specimen mislabeling in transfusion medicine. Arch Pathol Lab Med. 2006;130(8):1196-1198.
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Format:
Google S…
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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - bronchoscopy not only provides visualization of the lower
respiratory tract but can also allow for various sampling
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psnet.ahrq.gov/issue/blood-bank-specimen-mislabeling-college-american-pathologists-q-probes-study-41333-blood-bank
November 16, 2022 - Study
Blood bank specimen mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions.
Citation Text:
Novis DA, Lindholm PF, Ramsey G, et al. Blood Bank Specimen Mislabeling: A College of American Pathologists Q-Probes Study of 41 333 …
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psnet.ahrq.gov/node/49793/psn-pdf
May 01, 2017 - Hemolysis Holdup
May 1, 2017
Lehman CM. Hemolysis Holdup. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hemolysis-holdup
The Case
A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic
kidney disease, atrial fibrillation, and type 2 diabetes mellitus presented t…
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psnet.ahrq.gov/issue/emergency-departments-are-higher-risk-locations-wrong-blood-tube-errors
November 17, 2021 - Study
Emergency departments are higher-risk locations for wrong blood in tube errors.
Citation Text:
Dunbar NM, Delaney M, Murphy MF, et al. Emergency departments are higher‐risk locations for wrong blood in tube errors. Transfusion (Paris). 2021;61(9):2601-2610. doi:10.1111/trf.16588.
…
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psnet.ahrq.gov/issue/transfusion-safety-nature-and-outcomes-errors-patient-registration
December 16, 2020 - Review
Transfusion safety: the nature and outcomes of errors in patient registration.
Citation Text:
Cohen R, Ning S, Yan MTS, et al. Transfusion Safety: The Nature and Outcomes of Errors in Patient Registration. Transfus Med Rev. 2019;33(2):78-83. doi:10.1016/j.tmrv.2018.11.004.
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psnet.ahrq.gov/issue/sins-omission-getting-too-little-medical-care-may-be-greatest-threat-patient-safety
March 06, 2005 - Study
Sins of omission. Getting too little medical care may be the greatest threat to patient safety.
Citation Text:
Hayward RA, Asch SM, Hogan MM, et al. Sins of omission: getting too little medical care may be the greatest threat to patient safety. J Gen Intern Med. 2005;20(8):686-91…
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psnet.ahrq.gov/issue/using-ismp-medication-safety-self-assessment-improve-medication-use-processes
January 05, 2017 - Study
Using the ISMP Medication Safety Self-Assessment to improve medication use processes.
Citation Text:
Lesar TS, Mattis A, Anderson E, et al. Using the ISMP Medication Safety Self-Assessment to improve medication use processes. Jt Comm J Qual Saf. 2003;29(5):211-26.
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…
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psnet.ahrq.gov/issue/path-safety-benefits-2005-patient-safety-and-quality-improvement-act
June 03, 2015 - Commentary
Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act.
Citation Text:
McBride D, Greening A, Redmond D. Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act. Healthc Financ Manage. 2006;60(6):84-8.
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Form…
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psnet.ahrq.gov/web-mm/pathologic-mistake
February 15, 2010 - often exists on whether a given pathology error was secondary to misinterpretation or poor clinical sampling
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psnet.ahrq.gov/node/34010/psn-pdf
June 20, 2019 - ISMP Medication Safety Alert!® Nurse-Advise ERR.
June 20, 2019
Plymouth Meeting, PA: Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/ismp-medication-safety-alertr-nurse-advise-err
ISMP's newsletter was designed to specifically meet the needs of nurses who transcribe medication orders,
adminis…
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psnet.ahrq.gov/issue/national-incidence-medication-error-surgical-patients-and-after-accreditation-council
September 23, 2020 - Study
National incidence of medication error in surgical patients before and after Accreditation Council for Graduate Medical Education duty-hour reform.
Citation Text:
Vadera S, Griffith SD, Rosenbaum BP, et al. National Incidence of Medication Error in Surgical Patients Before and Afte…
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psnet.ahrq.gov/web-mm/hemolysis-holdup
July 03, 2016 - Hemolysis Holdup
Citation Text:
Lehman CM. Hemolysis Holdup. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
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…
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psnet.ahrq.gov/node/33729/psn-pdf
May 01, 2012 - per 100 admissions or per 1000
patient days)• Focuses on harm, but
includes errors as well• Allows sampling
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psnet.ahrq.gov/web-mm/real-heartache
October 01, 2018 - artery disease (e.g., untreated hypertension, cigarette smoking, and premature family history), serial sampling
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psnet.ahrq.gov/node/49679/psn-pdf
March 01, 2013 - Each lumen of
a multi-lumen catheter is used for a different purpose, such as sampling, total parenteral