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Medication-related medical emergency team activations: a case review study of frequency and preventability. | PSNet

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August 03, 2022 - to 20 hospitals in England during implementation of the 7-day services national health policy. … threats: a national survey of interns and residents. … Examining the frequency, types and senders of pages in academic medical services. … January 8, 2020 Experiences and perspectives of transgender youths in accessing health … care: a systematic review.

Allergy safety events in healthcare: development and application of a classification schema based on retrospective review. | PSNet

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December 09, 2020 - August 12, 2020 Communication with health care workers regarding health care-associated … June 24, 2020 Seroprevalence of SARS-CoV-2 among frontline health care personnel in a … August 3, 2022 Toward safer health care: a review strategy of FDA medical device adverse … to 20 hospitals in England during implementation of the 7-day services national health policy. … the National Academies' report Improving Diagnosis in Health Care.

The Unfinished Patient Safety Agenda | PSNet

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August 01, 2005 - Efforts to transform care at the bedside, including improved nurse staffing and working conditions, must … care services for the homeless. … in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and … June 25, 2014 Health Care Quality and Disparities: Lessons from the First National Reports … Health Care System.

Bleeding and in pain, a pregnant woman in Louisiana couldn’t get answers. | PSNet

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January 18, 2023 - March 3, 2021 Federal speech rulings may embolden health care workers to call out safety … January 17, 2024 Many people of color worry good health care is tied to their appearance … March 6, 2005 AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety … February 7, 2024 Silencing many hospital alarms leads to better health care. … November 30, 2022 'Reading the Signals' : Maternity and Neonatal Services in East Kent

Nurses as a source of system-level resilience: Secondary analysis of qualitative data from a study of intravenous infusion safety in English hospitals. | PSNet

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July 22, 2020 - February 5, 2020 Exploring nursing-sensitive events in home healthcare: a national multicenter … the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data … a multisite healthcare system. … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … and innovative approach to healthcare system safety.

In Conversation With… David Blumenthal, MD, MPP | PSNet

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July 01, 2012 - HealthCare System and Harvard Medical School. … In the present, it's better and almost everything we want to do to improve our health care system depends … For all I know, we will have such capable natural language processing that people will never look at … Statement of Commitment to Patient Safety and a Learning Healthcare System. … the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data

Deriving a framework for a systems approach to agitated patient care in the emergency department. | PSNet

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June 13, 2018 - to health care improvement. … November 16, 2022 Enabling a learning healthcare system with automated computer protocols … with language proficiency in the US. … March 18, 2015 Two-state collaborative study of a multifaceted intervention to decrease … May 12, 2021 Preventable medication harm across health care settings: a systematic review

Technical mistakes during the acquisition of the electrocardiogram. | PSNet

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March 09, 2022 - care from emergency medical services: a multi-center cross-sectional study. … May 2, 2007 Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate … a multisite healthcare system. … December 15, 2021 Coping strategies in health care providers as second victims: a systematic … 18, 2019 Incidence of adverse events related to health care in Spain: results of the

Diagnostic Delay in the Emergency Department | PSNet

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January 01, 2016 - Describe recommendations and approaches for individual physicians and health care organizations to address … [Available at] 7. Balogh EP, Miller BT, Ball JR, eds. Improving Diagnosis in Health Care. … Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine … Editorial: Helping health care organizations to define diagnostic errors as missed opportunities in diagnosis … Oper Res Health Care. 2013;2:66-74. [Available at] 30. Upadhyay DK, Sittig DF, Singh H.

Human Factors Engineering Can Teach You How to Be Surprised Again | PSNet

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November 01, 2006 - In: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. … RW: How would you try to apply this thinking in a health care organization? … Health Care January 1, 2017 Global State of Patient Safety 2023. … September 12, 2007 Improving the Reliability of Health Care. … and innovative approach to healthcare system safety.

In Conversation with...Sorrel King | PSNet

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March 01, 2007 - , or do something for kids in the health care setting. … You've got to look at the patient. … In some ways, you look at the steps that Hopkins has taken and it shows a lot of good people getting … have three roles in improving patient safety: helping to ensure their own safety, working with health … A second role for patients and family members is in working to improve safety and quality in health care

Caution, Interrupted | PSNet

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October 01, 2016 - Similar efforts have begun in some areas of health care ( 14 ), but have yet to be implemented in a comprehensive … is new to health care, called "technical work studies … health care providers. … The messy details: insights from technical work studies in health care. … Louis Health Care System in Missouri.

Improving resident engagement in quality improvement and patient safety initiatives at the bedside: the Advocate for Clinical Education (ACE). | PSNet

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August 26, 2015 - Improving resident engagement in quality improvement and patient safety initiatives at the bedside: the … Improving resident engagement in quality improvement and patient safety initiatives at the bedside: the … June 7, 2023 Seroprevalence of SARS-CoV-2 among frontline health care personnel in a … One health care system's experience. … among older adults receiving home health care.

Interventions targeted at reducing diagnostic error: systematic review. | PSNet

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September 01, 2021 - to 20 hospitals in England during implementation of the 7-day services national health policy. … in adverse event rates in the Irish healthcare system. … February 3, 2021 Interventions into reliability-seeking health care organizations: a … August 17, 2022 Stigma and healthcare access among transgender and gender-diverse people … National Academies' report Improving Diagnosis in Health Care.

What whiteboards in a trauma center operating suite can teach us about emergency department communication. | PSNet

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May 02, 2007 - January 12, 2022 Enabling a learning healthcare system with automated computer protocols … eight health care organizations. … discrepancies for patients transitioning from hospital to home health care. … July 14, 2021 Communication in health care: impact of language and accent on health care … health care.

Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings. | PSNet

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August 10, 2022 - to 20 hospitals in England during implementation of the 7-day services national health policy. … in a learning healthcare system: results of the DEMEANOR pragmatic, cluster, cross-over trial. … December 6, 2023 Fragmented: A Doctor's Quest to Piece Together American Health Care. … August 31, 2022 Health care quality and safety in a correctional system: creating goals … August 10, 2022 Outsourcing health-care services to the private sector and treatable

Safer Services: A Toolkit for Specialist Mental Health Services and Primary Care. | PSNet

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November 25, 2009 - August 5, 2020 Patient safety monitoring in acute care in a decentralized national health … care system: conceptual framework and initial set of actionable indicators. … March 21, 2018 Communication in health care: impact of language and accent on health … infections in 2020: a summary of data reported to the National Healthcare Safety Network. … December 7, 2022 A look into the nature and causes of human errors in the intensive care

Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. | PSNet

psnet.ahrq.gov/issue/learning-mistakes-easier-said-done-group-and-organizational-influences-detection-and

December 16, 2020 - Edmondson proposes that, rather than examining errors and accidents in health care on an individual or … May 11, 2016 Organizational learning: health care leaders need to design structures and … March 6, 2005 Improving medication reconciliation with comprehensive evaluation at a … a multisite healthcare system. … April 29, 2020 Zero harm in health care.

Speaking up: factors and issues in nurses advocating for patients when patients are in jeopardy. | PSNet

psnet.ahrq.gov/issue/speaking-factors-and-issues-nurses-advocating-patients-when-patients-are-jeopardy

March 29, 2023 - July 22, 2020 Latent safety threats and countermeasures in the operating theater: a national … to prioritize efforts to improve cancer care delivery. … in health care: a battle to be heard, believed, and protected. … expansion of tools and services in the Veterans Health Administration. … April 25, 2018 Taking bullying out of health care: a patient safety imperative.

What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety | PSNet

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March 01, 2017 - Books and articles attesting to the importance of patient safety culture in health care are now plentiful … In contrast, health care leaders can undermine their ability to affect lasting change and create a learning … A common complaint among health care professionals is that there is "never enough time to work on culture … November 25, 2015 Achieving Safe Health Care: Delivery of Safe Patient Care at Baylor … March 8, 2006 The Ethics of Using QI Methods to Improve Health Care Quality and Safety

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