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psnet.ahrq.gov/issue/how-will-we-know-patients-are-safer-organization-wide-approach-measuring-and-improving-safety
May 20, 2009 - They provide a case-type example of their suggested process to illustrate their framework.
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psnet.ahrq.gov/issue/types-unintended-consequences-related-computerized-provider-order-entry
February 18, 2011 - Study
Classic
Types of unintended consequences related to computerized provider order entry.
Citation Text:
Campbell EM, Sittig DF, Ash JS, et al. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13(5):…
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psnet.ahrq.gov/node/867751/psn-pdf
March 12, 2025 - Using three triggers and the Revised Safer Dx
Instrument, this study uncovered the frequency, type,
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psnet.ahrq.gov/node/33568/psn-pdf
June 15, 2024 - Factors That May Lead to Latent Errors
Type of Factor Example
Institutional/regulatory
A patient on … psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
Type
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psnet.ahrq.gov/issue/incidence-and-types-preventable-adverse-events-elderly-patients-population-based-review
June 23, 2015 - Study
Classic
Incidence and types of preventable adverse events in elderly patients: population based review of medical records.
Citation Text:
Thomas EJ, Brennan TA. Incidence and types of preventable adverse events in elderly patients: population based revie…
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psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - So, I would say reporting the wrong type of events is another problem, meaning that incident reports … That's a very structured type of data collection. … The arguments for the centrality and the commonality type of approach are obvious. … And then some things are more common, human factors type stuff, especially equipment design. … It would be really important to know if the same type of smart pump is causing the same type of problems
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - An intravenous (IV) line was placed and a “type and cross for blood” request was sent along with baseline … service QMS must include a closed-loop process that protects patients from an ABO-incompatible (blood type-incompatible … One potential corrective action is to implement bedside sample labeling for all blood-type verifications
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psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
March 15, 2023 - The exact type of e-cigarette the patient used was not known. … It is not known what type of e-cigarette was used by this patient, but the type of product is relevant … smoking (mostly a problem with cigarette-like disposable devices), avoiding renormalization of smoking-type
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psnet.ahrq.gov/issue/types-diagnostic-errors-reported-paediatric-emergency-providers-global-paediatric-emergency
December 16, 2020 - Study
Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network.
Citation Text:
Mahajan P, Grubenhoff JA, Cranford J, et al. Types of diagnostic errors reported by paediatric emergency providers in a global paediatric eme…
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psnet.ahrq.gov/issue/frequency-and-types-patient-reported-errors-electronic-health-record-ambulatory-care-notes
June 05, 2019 - Study
Classic
Frequency and types of patient-reported errors in electronic health record ambulatory care notes.
Citation Text:
Bell SK, Delbanco T, Elmore JG, et al. Frequency and types of patient-reported errors in electronic health record ambulatory care notes…
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psnet.ahrq.gov/issue/adverse-drug-events-after-hospital-discharge-older-adults-types-severity-and-involvement
August 11, 2010 - Study
Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers criteria medications.
Citation Text:
Kanaan AO, Donovan JL, Duchin NP, et al. Adverse drug events after hospital discharge in older adults: types, severity, and involvement of …
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psnet.ahrq.gov/node/33585/psn-pdf
March 15, 2025 - Nuclear medicine scans use a special type of camera that images gamma-
radiation–emitting radioisotopes … One study showed that even for the same type of CT examination, the radiation doses
varied as much as
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psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and
April 06, 2011 - Study
Classic
Communication failures in the operating room: an observational classification of recurrent types and effects.
Citation Text:
Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recu…
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psnet.ahrq.gov/web-mm/nstemi-curbside-consultation
August 04, 2021 - The 4th Universal Definition of Myocardial Infarction 22 states that “demand ischemia” represents type … In addition, at least one of the following criteria is needed to diagnose type 2 MI: a) symptoms of acute … In addition, type 2 MI and myocardial injury are both related to poor outcomes, and ischemia thresholds … Diagnosing Type 2 Myocardial Infarction: American College of Cardiology Expert Analysis; 2016 [Available … Assessment and Treatment of Patients With Type 2 Myocardial Infarction and Acute Nonischemic Myocardial
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psnet.ahrq.gov/node/33564/psn-pdf
March 15, 2025 - Computerized Provider Order Entry
March 15, 2025
Computerized Provider Order Entry. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/computerized-provider-order-entry
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice…
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - and are higher in pregnant women who are obese, African American, older than 35 years, and who have type … hypertension is approximately 20%; this risk is markedly increased in patients with twins and in those with type … These included orders for type and frequency of blood tests, fetal monitoring, and surveillance of symptoms … How can we avoid this type of error?
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psnet.ahrq.gov/primer/surgical-site-infections
December 15, 2024 - that occurs at or near the surgical incision within 30 to 90 days of the procedure, depending on the type
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psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something
May 01, 2019 - Incidence and risk factors for HBV reactivation The risk for HBV reactivation is influenced by both the type … The risk for reactivation of hepatitis B depends on the type of chemotherapy and is, therefore, indirectly … associated with the type of malignancy.
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psnet.ahrq.gov/issue/anticoagulant-safety-practices-call-pharmacist-supervision
May 08, 2024 - March 20, 2017
Frequency and type of errors and near errors reported by critical care
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psnet.ahrq.gov/issue/nursing-interventions-reduce-medication-errors-paediatrics-and-neonates-systematic-review-and
November 24, 2021 - Review
Nursing interventions to reduce medication errors in paediatrics and neonates: systematic review and meta-analysis.
Citation Text:
Marufu TC, Bower R, Hendron E, et al. Nursing interventions to reduce medication errors in paediatrics and neonates: systematic review and meta-analys…