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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.37_slideshow.ppt
November 01, 2003 - Spotlight Case [MONTH] 2003
Spotlight Case November 2003
The Missing Suction Tip
Source and Credits
This presentation is based on the Nov. 2003
AHRQ WebM&M Spotlight Case in Surgery
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Eric J. Thomas, MD,…
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psnet.ahrq.gov/node/73995/psn-pdf
October 20, 2021 - Potential for medication overdose with ENFit low dose tip
syringe: FDA Safety Communication.
October 20, 2021
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 12, 2021.
https://psnet.ahrq.gov/issue/potential-medication-overdose-enfit-low-dose-tip-syringe-fda-safety-
communication
…
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psnet.ahrq.gov/node/43017/psn-pdf
June 12, 2019 - leaflet offers information to
help clinicians understand the value of effective apologies along with tips
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psnet.ahrq.gov/node/837433/psn-pdf
June 15, 2022 - Unacceptable behaviours between healthcare workers:
just the tip of the patient safety iceberg.
June 15, 2022
Bamberger E, Bamberger P. Unacceptable behaviours between healthcare workers: just the tip of the
patient safety iceberg. BMJ Qual Saf. 2022;31(9):638-641. doi:10.1136/bmjqs-2021-014157.
https://psnet.ahrq…
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psnet.ahrq.gov/node/837802/psn-pdf
August 10, 2022 - Tipping the balance: a systematic review and meta-
ethnography to unfold the complexity of surgical
antimicrobial prescribing behavior in hospital settings.
August 10, 2022
Parker H, Frost J, Day J, et al. Tipping the balance: a systematic review and meta-ethnography to unfold
the complexity of surgical antimicrob…
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psnet.ahrq.gov/issue/reducing-medical-error-military-health-system-how-can-team-training-help
March 29, 2007 - March 6, 2013
Debriefing medical teams: 12 evidence-based best practices and tips. … November 11, 2009
Communicating, coordinating, and cooperating when lives depend on it: tips
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psnet.ahrq.gov/node/46039/psn-pdf
April 05, 2017 - Retained lumbar catheter tip.
April 5, 2017
DeLancey JO, Barnard C, Bilimoria KY. Retained Lumbar Catheter Tip. JAMA. 2017;317(12):1269-1270.
doi:10.1001/jama.2017.1713.
https://psnet.ahrq.gov/issue/retained-lumbar-catheter-tip
Retained surgical items are considered a sentinel event. Discussing an incident involvi…
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis
June 16, 2019 - selection of medication error reports provides examples from the field of potential errors and helpful tips
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psnet.ahrq.gov/node/38493/psn-pdf
March 18, 2009 - finding-way-ask-doctors-tough-questions
This article encourages patients to be assertive about their care and provides tips
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psnet.ahrq.gov/node/43313/psn-pdf
April 22, 2015 - Stress on the ward: evidence of safety tipping points in
hospitals.
April 22, 2015
Kuntz L, Mennicken R, Scholtes S. Stress on the Ward: Evidence of Safety Tipping Points in Hospitals.
Manage Sci. 2014;61(4). doi:10.1287/mnsc.2014.1917.
https://psnet.ahrq.gov/issue/stress-ward-evidence-safety-tipping-points-hospit…
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psnet.ahrq.gov/node/39129/psn-pdf
November 25, 2009 - how-avoid-falling-victim-hospital-mistake
This news story describes an incident of patient misidentification and offers tips
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psnet.ahrq.gov/node/41655/psn-pdf
February 01, 2015 - project-jessica
This video chronicles how an undiagnosed heart condition led to a teenager's death and offers tips
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psnet.ahrq.gov/node/37553/psn-pdf
February 20, 2008 - This publication discusses patient safety in ambulatory care and provides business cases, technology tips
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psnet.ahrq.gov/node/37741/psn-pdf
January 10, 2017 - Error-avoidance recommendations for tubing
misconnections when using luer-tip connectors: a
statement by the USP Safe Medication Use Expert
Committee.
January 10, 2017
Simmons D, Phillips MS, Grissinger M, et al. Error-avoidance recommendations for tubing misconnections
when using Luer-tip connectors: a statement…
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psnet.ahrq.gov/node/40631/psn-pdf
July 27, 2011 - magazine article discusses several cases of misdiagnosis, explores reasons for errors, and provides
tips
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psnet.ahrq.gov/node/39593/psn-pdf
June 09, 2010 - look-alike-sound-alike-drugs-trigger-dangers
This news piece details errors involving medication name confusion and presents tips
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psnet.ahrq.gov/node/41529/psn-pdf
July 18, 2012 - error disclosure, describes the emotional impact medical errors can
have on physicians, and provides tips
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psnet.ahrq.gov/node/33898/psn-pdf
October 03, 2012 - Quick Tips for Buying Medicines Over the Internet.
October 3, 2012
Food and Drug Administration.
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psnet.ahrq.gov/node/34123/psn-pdf
November 02, 2014 - This patient fact sheet outlines
practical tips to minimize risk.
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psnet.ahrq.gov/node/40591/psn-pdf
July 06, 2011 - discusses a case of diagnostic error, explores the complexity of the diagnostic
process, and provides tips