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psnet.ahrq.gov/node/49425/psn-pdf
November 01, 2003 - Defenses could be built in at many stages, depending on the outcome of the investigation.
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psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
May 22, 2024 - and institutional administration may better address the impact of medical errors on caregivers at all stages
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
October 01, 2010 - Spotlight Case July 2008
Spotlight Case October 2010
Dangerous Dialysis
*
*
Source and Credits
This presentation is based on the October 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…
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psnet.ahrq.gov/node/612828/psn-pdf
February 23, 2022 - Delayed Diagnosis of Kidney Transplant Complications
February 23, 2022
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
Objectives
Recognition, early evaluation, and management of kidney …
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psnet.ahrq.gov/issue/nrcpr-project-information-medical-emergencyrapid-response-teams-metrrt
March 29, 2006 - Tools/Toolkit
Toolkit
Published March 29, 2006
NRCPR Project Information: Medical Emergency/Rapid Response Teams (MET/RRT).
National Registry of CPR; Amercan Heart Association; NRCPR; AHA
Topics
…
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psnet.ahrq.gov/node/46624/psn-pdf
November 29, 2017 - Empowerment failure: how shortcomings in physician
communication unwittingly undermine patient autonomy.
November 29, 2017
Ubel PA, Scherr KA, Fagerlin A. Empowerment Failure: How Shortcomings in Physician Communication
Unwittingly Undermine Patient Autonomy. Am J Bioeth. 2017;17(11):31-39.
doi:10.1080/15265161.20…
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psnet.ahrq.gov/node/40167/psn-pdf
January 22, 2017 - Trainees' perceptions of patient safety practices:
recounting failures of supervision.
January 22, 2017
Ross PT, McMyler ET, Anderson SG, et al. Trainees' perceptions of patient safety practices: recounting
failures of supervision. Jt Comm J Qual Patient Saf. 2011;37(2):88-95.
https://psnet.ahrq.gov/issue/trainees…
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psnet.ahrq.gov/node/49609/psn-pdf
October 01, 2010 - Dangerous Dialysis
October 1, 2010
Holley JL. Dangerous Dialysis . PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/dangerous-dialysis
Case Objectives
List common errors that occur in dialysis units.
Describe steps that can be taken by dialysis units to prevent these common errors.
Describe the role of the …
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psnet.ahrq.gov/node/49534/psn-pdf
May 01, 2007 - Antiseizure Medication Disorder
May 1, 2007
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
Case Objectives
Appreciate the challenges of safe use of antiepileptic medications.
Identify phenytoin toxicity.
Understand the pharmaco…
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psnet.ahrq.gov/node/37838/psn-pdf
June 11, 2008 - Mitigation of patient harm from testing errors in family
medicine offices: a report from the American Academy of
Family Physicians National Research Network.
June 11, 2008
Graham DG, Harris DM, Elder NC, et al. Mitigation of patient harm from testing errors in family medicine
offices: a report from the American Ac…
-
psnet.ahrq.gov/node/42968/psn-pdf
February 26, 2014 - From physician intent to the pharmacy label: prevalence
and description of discrepancies from a cross-sectional
evaluation of electronic prescriptions.
February 26, 2014
Cochran GL, Klepser DG, Morien M, et al. From physician intent to the pharmacy label: prevalence and
description of discrepancies from a cross-se…
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psnet.ahrq.gov/node/45893/psn-pdf
August 28, 2017 - Exploring the roots of unintended safety threats
associated with the introduction of hospital ePrescribing
systems and candidate avoidance and/or mitigation
strategies: a qualitative study.
August 28, 2017
Mozaffar H, Cresswell K, Williams R, et al. Exploring the roots of unintended safety threats associated with
…
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psnet.ahrq.gov/node/43388/psn-pdf
July 30, 2014 - Exploration of an automated approach for receiving
patient feedback after outpatient acute care visits.
July 30, 2014
Berner ES, Ray MN, Panjamapirom A, et al. Exploration of an automated approach for receiving patient
feedback after outpatient acute care visits. J Gen Intern Med. 2014;29(8):1105-12. doi:10.1007/s1…
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psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
April 24, 2024 - Extravasation may be categorized into 4 stages according to the severity of the injury, as described
-
psnet.ahrq.gov/node/848109/psn-pdf
April 26, 2023 - Extravasation may be categorized into 4 stages according to the severity of the injury, as described
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.149_slideshow.ppt
May 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case May 2007
Antiseizure Medication Disorder
Source and Credits
This presentation is based on the May 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Brian K. Alldredge, Pharm…
-
psnet.ahrq.gov/node/43865/psn-pdf
May 01, 2015 - Computerised physician order entry-related medication
errors: analysis of reported errors and vulnerability
testing of current systems.
May 1, 2015
Schiff GD, Amato MG, Eguale T, et al. Computerised physician order entry-related medication errors:
analysis of reported errors and vulnerability testing of current sy…
-
psnet.ahrq.gov/node/39549/psn-pdf
March 22, 2011 - The impact of traditional and smart pump infusion
technology on nurse medication administration
performance in a simulated inpatient unit.
March 22, 2011
Trbovich PL, Pinkney S, Cafazzo JA, et al. The impact of traditional and smart pump infusion technology on
nurse medication administration performance in a simul…
-
psnet.ahrq.gov/node/50393/psn-pdf
September 01, 2019 - From the early stages of the
patient safety field, beginning with the 1999 To Err Is Human report,
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psnet.ahrq.gov/node/49813/psn-pdf
January 01, 2018 - While palliative care may be beneficial for patients at various stages of serious illness, to be
eligible