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psnet.ahrq.gov/node/47471/psn-pdf
January 27, 2019 - This secondary data analysis of all single-eye cataract surgeries performed in
Ontario between 2009
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psnet.ahrq.gov/node/44346/psn-pdf
March 18, 2016 - to
include four primary care–specific domains: continuity of care, external policy context, primary–secondary
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psnet.ahrq.gov/issue/time-get-pigs-back-human-factors-aspects-mismatch-between-device-and-real-world-knowledge
June 09, 2011 - The authors analyzed secondary (piggyback) infusions at their institution to illustrate human factors
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psnet.ahrq.gov/issue/maternal-and-infant-health-inequality-new-evidence-linked-administrative-data
August 23, 2017 - the alignment of economic stability with maternal and infant care quality and found parental income secondary
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psnet.ahrq.gov/issue/rapid-response-teams-patient-safety-practice-failure-rescue
January 26, 2022 - The authors note that evidence does support that RRTs are associated with reduced secondary outcomes,
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psnet.ahrq.gov/issue/misdiagnosis-thoracic-aortic-emergencies-occurs-frequently-among-transfers-aortic-referral
October 28, 2020 - Approximately 11% of emergency transfers were misdiagnosed, secondary to imaging misinterpretation.
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psnet.ahrq.gov/issue/understanding-peer-manager-and-system-influence-patient-safety
July 22, 2020 - This secondary analysis of Hospital Survey on Patient Safety scores indicate that manager - and peer-level
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psnet.ahrq.gov/issue/how-providers-can-optimize-effective-and-safe-scribe-use-qualitative-study
November 18, 2020 - In this secondary analysis, researchers identified three themes for safe use of medical scribes: communication
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psnet.ahrq.gov/issue/effects-individual-nurse-and-hospital-characteristics-patient-adverse-events-and-quality-care
February 08, 2019 - This secondary analysis combined survey data from individual nurses with hospital safety culture data
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psnet.ahrq.gov/issue/beyond-error-qualitative-study-human-factors-serious-adverse-events
December 18, 2024 - July 22, 2020
Differences between methods of detecting medication errors: a secondary
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psnet.ahrq.gov/issue/world-sepsis-day
May 12, 2021 - July 8, 2020
Differences between methods of detecting medication errors: a secondary
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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - Image adapted and printed with permission from Pinkney et al., 2014 17 Errors Associated with Secondary … Infusions Secondary (“piggyback”) infusions are IV infusions that are attached to the primary continuous … Medication errors associated with secondary infusions arise from their complex setup process and include … infusion bags, and programming errors. 24 Secondary infusion errors accounted for approximately 39% … /piggyback infusion. 42 Attachment of a secondary infusion may result in transition of a continuous
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psnet.ahrq.gov/node/46893/psn-pdf
March 21, 2018 - inform
initiatives to reduce high-risk prescribing, promote medication-assisted treatment, and improve secondary
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psnet.ahrq.gov/node/45080/psn-pdf
February 15, 2017 - low tidal volumes, central venous catheters, and urinary catheters, but there was no difference in
secondary
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psnet.ahrq.gov/node/47189/psn-pdf
August 17, 2018 - This secondary data analysis of more than 100,000 patients
undergoing in-hospital surgical procedures
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.359_slideshow.ppt
October 01, 2015 - patient care data
3
Case: The Risks of Absent Interoperability
A 47-year-old man with paraplegia (secondary … leaving.
4
Case: The Risks of Absent Interoperability (2)
The patient was again diagnosed with sepsis secondary … in the ICU, the patient's hemoglobin was undetectable, and clinicians determined that the arrest was secondary
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psnet.ahrq.gov/issue/speaking-and-sharing-information-improves-trainee-neonatal-resuscitations
April 08, 2011 - This secondary analysis of a teamwork training trial identified the specific teamwork behaviors that
-
psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - with nocturnal angina do not have obstructive coronary artery disease, making their symptoms likely secondary … Stress testing is the modality of choice in determining if a patient’s symptoms are likely secondary … The impact of pharmacists-led medicines reconciliation on healthcare outcomes in secondary … May 26, 2021
WebM&M Cases
Hyponatremia Secondary
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psnet.ahrq.gov/node/45330/psn-pdf
August 03, 2016 - Medicare Patient Safety Monitoring System and the Centers for Medicare and Medicaid
Services, this secondary
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psnet.ahrq.gov/issue/diseases-medical-progress
June 27, 2018 - Many of these continue to treat one illness but place patients at risk for developing a secondary condition