Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
1 - 7 of 7
Soncrant C, Mills PD, Neily J, et al. J Patient Saf. 2020;16:41-46.
In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.
A man with paraplegia was admitted to the hospital, but the admitting physician, night float resident, and daytime team all "deferred" examination of the genital area. The patient was later discovered to have life-threatening necrotizing fasciitis of this area.
Stein R; USP; United States Pharmacopeia
This article reports on an analysis of data collected by United States Pharmacopeia's voluntary reporting program that found medication errors are seven times more likely to occur during radiological procedures.
An unclear verbal order leads to administration of the wrong drug.
A blood-soaked BP cuff used on one trauma patient is re-used on the next trauma patient, with no regard to universal precautions.