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psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
March 21, 2009 - Within a minute, he developed severe abdominal pain and bone pain.
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psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - The practice of RCA for sentinel events (e.g., incidents resulting
in death, permanent harm, or severe
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psnet.ahrq.gov/node/50768/psn-pdf
December 27, 2019 - that found that hospital patients with limited English proficiency
experienced more harms and more severe
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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - stroke due to left posterior cerebral artery occlusion and vertebral artery dissection, leading to severe
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psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
November 27, 2019 - Magnetic resonance imaging (MRI) revealed severe spinal stenosis involving C3-4 and post-traumatic cord
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psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
July 02, 2019 - Most notable were severe nausea and vomiting due to abdominal pain and chemotherapy leading to dehydration
-
psnet.ahrq.gov/node/848083/psn-pdf
April 26, 2023 - Economic evaluations of interventions to prevent and
control health-care-associated infections: a systematic
review.
April 26, 2023
Rice S, Carr K, Sobiesuo P, et al. Economic evaluations of interventions to prevent and control health-care-
associated infections: a systematic review. Lancet Infect Dis. 2023;23(7):…
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psnet.ahrq.gov/node/838176/psn-pdf
September 28, 2022 - Challenges and strategies for patient safety in primary
care: a qualitative study.
September 28, 2022
Yuan CT, Dy SM, Yuanhong Lai A, et al. Challenges and strategies for patient safety in primary care: a
qualitative study. Am J Med Qual. 2022;37(5):379-387. doi:10.1097/jmq.0000000000000054.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/43594/psn-pdf
May 01, 2015 - Impact of introducing an electronic physiological
surveillance system on hospital mortality.
May 1, 2015
Schmidt PE, Meredith P, Prytherch DR, et al. Impact of introducing an electronic physiological surveillance
system on hospital mortality. BMJ Qual Saf. 2015;24(1):10-20. doi:10.1136/bmjqs-2014-003073.
https://p…
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psnet.ahrq.gov/issue/emergency-nursing-and-medical-error-survey-two-states
January 25, 2010 - December 1, 2011
Are temporary staff associated with more severe emergency department
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psnet.ahrq.gov/issue/ismp-quarterwatch-reports
June 07, 2017 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
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psnet.ahrq.gov/issue/2017-ismp-medication-safety-self-assessment-communityambulatory-pharmacy
June 07, 2017 - May 11, 2017
Severe hyperglycemia in patients incorrectly using insulin pens at home.
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psnet.ahrq.gov/issue/patient-safety-24
December 01, 2011 - July 8, 2013
Are temporary staff associated with more severe emergency department medication
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psnet.ahrq.gov/issue/nursing-care-quality-nqf
September 06, 2011 - July 8, 2009
Antecedents of severe and nonsevere medication errors.
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psnet.ahrq.gov/node/49811/psn-pdf
November 01, 2017 - worsening respiratory status, liver abnormalities, and colonic pseudo-obstruction were all
consistent with severe … These are rare but life-threatening conditions that result from either decompensated
thyrotoxicosis or severe … Effects Score
Absent 0
Mild (agitation) 10
Moderate (delirium, psychosis, extreme lethargy) 20
Severe … 25
Congestive Heart Failure Score
Absent 0
Mild (pedal edema) 5
Moderate (bibasilar rales) 10
Severe
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
July 01, 2003 - advanced care discussions
Case: Code Status Confusion
A 60-year-old woman with a history of severe … preferences in scenarios with uncertain outcomes
i.e., successful cardiac resuscitation with resultant severe
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psnet.ahrq.gov/issue/10-medication-safety-tips-hospitalized-patients
February 06, 2019 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
-
psnet.ahrq.gov/issue/ismp-long-term-care-advise-err
June 07, 2017 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
-
psnet.ahrq.gov/issue/clinical-issues-series
July 05, 2006 - 2006
National Partnership for Maternal Safety: consensus bundle on support after a severe
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psnet.ahrq.gov/issue/fatal-gas-line-mix-how-avoid-making-gastly-mistake
April 29, 2018 - September 12, 2016
ALERT: reports of severe harm after intravenous administration of