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  1. A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning. | PSNet

    psnet.ahrq.gov/issue/crack-our-best-armor-wrong-patient-injections-insulin-pens-alarmingly-frequent-even-barcode
    October 22, 2014 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … May 29, 2019 ISMP medication error report analysis.

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43777/psn-pdf
    January 01, 2015 - Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. … Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. … https://psnet.ahrq.gov/issue/smartphones-let-surgeons-know-whatsapp-analysis-communication- emergency-surgical-teams … Analysis of messages found it to be a safe and efficient method of communication that was perceived … https://psnet.ahrq.gov/issue/smartphones-let-surgeons-know-whatsapp-analysis-communication-emergency-surgical-teams

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38735/psn-pdf
    June 24, 2009 - Reflection and analysis of how pharmacy students learn to communicate about medication errors. … Reflection and analysis of how pharmacy students learn to communicate about medication errors. … https://psnet.ahrq.gov/issue/reflection-and-analysis-how-pharmacy-students-learn-communicate-about- … https://psnet.ahrq.gov/issue/reflection-and-analysis-how-pharmacy-students-learn-communicate-about-medication-errors … https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine https://psnet.ahrq.gov

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38207/psn-pdf
    January 15, 2009 - Analysis of medical emergency team calls comparing subjective to "objective" call criteria. … Analysis of medical emergency team calls comparing subjective to "objective" call criteria. … https://psnet.ahrq.gov/issue/analysis-medical-emergency-team-calls-comparing-subjective-objective-call … This analysis conducted at six Australian hospitals found that nurses' general concern about a patient … https://psnet.ahrq.gov/issue/analysis-medical-emergency-team-calls-comparing-subjective-objective-call-criteria

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43565/psn-pdf
    March 22, 2016 - The role of failure mode and effects analysis in health care. March 22, 2016 Fibuch E, Ahmed A. … The role of failure mode and effects analysis in health care. Physician Exec. 2014;40(4):28-32. … https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care Failure mode and effects … analysis (FMEA) has been recommended as a method to detect safety hazards and proactively address system … https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care https://psnet.ahrq.gov

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43997/psn-pdf
    August 02, 2015 - Sentinel events, serious reportable events, and root cause analysis. … Sentinel events, serious reportable events, and root cause analysis. … https://psnet.ahrq.gov/issue/sentinel-events-serious-reportable-events-and-root-cause-analysis This … authors use ophthalmologic examples to illustrate the elements of a systematic approach to root cause analysis … https://psnet.ahrq.gov/issue/sentinel-events-serious-reportable-events-and-root-cause-analysis https:

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43501/psn-pdf
    September 10, 2014 - Emergency department patient safety incident characterization: an observational analysis of the findings … Emergency department patient safety incident characterization: an observational analysis of the findings … /psnet.ahrq.gov/issue/emergency-department-patient-safety-incident-characterization-observational- analysis-findings … Analysis of the data revealed that most emergency department patient safety incidents were primarily … ://psnet.ahrq.gov/issue/emergency-department-patient-safety-incident-characterization-observational-analysis-findings

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42469/psn-pdf
    August 07, 2013 - Characteristics of paid malpractice claims settled in and out of court in the USA: a retrospective analysis … Characteristics of paid malpractice claims settled in and out of court in the USA: a retrospective analysis … psnet.ahrq.gov/issue/characteristics-paid-malpractice-claims-settled-and-out-court-usa- retrospective-analysis … This analysis of paid malpractice claims from the National Practitioner Data Bank found that the vast … psnet.ahrq.gov/issue/characteristics-paid-malpractice-claims-settled-and-out-court-usa-retrospective-analysis

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45666/psn-pdf
    April 24, 2018 - The relationship between professional burnout and quality and safety in healthcare: a meta-analysis. … The Relationship Between Professional Burnout and Quality and Safety in Healthcare: A Meta-Analysis. … psnet.ahrq.gov/issue/relationship-between-professional-burnout-and-quality-and-safety-healthcare- meta-analysis … This meta-analysis examined the relationship of burnout to health care quality. … In the pooled analysis, higher levels of burnout were associated with lower reported quality and safety

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44252/psn-pdf
    January 01, 2016 - Associations between safety culture and employee engagement over time: a retrospective analysis. … Associations between safety culture and employee engagement over time: a retrospective analysis. … psnet.ahrq.gov/issue/associations-between-safety-culture-and-employee-engagement-over-time- retrospective-analysis … This secondary analysis examined the relationship between safety culture and employee engagement. … psnet.ahrq.gov/issue/associations-between-safety-culture-and-employee-engagement-over-time-retrospective-analysis

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43332/psn-pdf
    July 09, 2014 - Interventions to reduce the consequences of stress in physicians: a review and meta-analysis. … Interventions to reduce the consequences of stress in physicians: a review and meta-analysis. … https://psnet.ahrq.gov/issue/interventions-reduce-consequences-stress-physicians-review-and-meta- analysis … According to this meta-analysis, interventions that applied cognitive, behavioral, and mindfulness … https://psnet.ahrq.gov/issue/interventions-reduce-consequences-stress-physicians-review-and-meta-analysis

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41724/psn-pdf
    January 01, 2013 - Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug … Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug … https://psnet.ahrq.gov/issue/using-healthcare-failure-mode-and-effect-analysis-reduce-medication-errors … - process-drug In this study, failure mode and effect analysis—a prospective risk assessment tool—successfully … https://psnet.ahrq.gov/issue/using-healthcare-failure-mode-and-effect-analysis-reduce-medication-errors-process-drug

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39064/psn-pdf
    October 28, 2009 - Use of failure mode and effects analysis for proactive identification of communication and handoff failures … Use of failure mode and effects analysis for proactive identification of communication and handoff failures … https://psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-proactive-identification-communication … - and-handoff Failure mode and effects analysis was used to identify vulnerable handoff and communication … https://psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-proactive-identification-communication-and-handoff

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43988/psn-pdf
    February 22, 2018 - rate of implementation of proposed actions for improvement with the Healthcare Failure Mode Effect Analysis … Rate of Implementation of Proposed Actions for Improvement With the Healthcare Failure Mode Effect Analysis … psnet.ahrq.gov/issue/high-rate-implementation-proposed-actions-improvement-healthcare-failure- mode-effect-analysis … Failure mode effect analysis is a widely used method of prospectively detecting safety hazards, but … psnet.ahrq.gov/issue/high-rate-implementation-proposed-actions-improvement-healthcare-failure-mode-effect-analysis

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44285/psn-pdf
    November 06, 2015 - Hospital board oversight of quality and safety: a stakeholder analysis exploring the role of trust and … Hospital board oversight of quality and safety: a stakeholder analysis exploring the role of trust and … https://psnet.ahrq.gov/issue/hospital-board-oversight-quality-and-safety-stakeholder-analysis-exploring … Trust among organizational leadership and prioritization of data analysis emerged as important methods … https://psnet.ahrq.gov/issue/hospital-board-oversight-quality-and-safety-stakeholder-analysis-exploring-role-trust-and

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46642/psn-pdf
    December 13, 2017 - Intravenous fluid prescribing errors in children: mixed methods analysis of critical incidents. … Intravenous fluid prescribing errors in children: Mixed methods analysis of critical incidents. … https://psnet.ahrq.gov/issue/intravenous-fluid-prescribing-errors-children-mixed-methods-analysis-critical … This analysis of critical incident reports related to intravenous fluid prescribing errors among children … https://psnet.ahrq.gov/issue/intravenous-fluid-prescribing-errors-children-mixed-methods-analysis-critical-incidents

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45609/psn-pdf
    November 16, 2016 - A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. … A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. … https://psnet.ahrq.gov/issue/review-healthcare-failure-mode-and-effects-analysis-hfmea-radiotherapy … Health care failure mode and effect analysis (HFMEA) was developed by the Veterans Affairs health system … https://psnet.ahrq.gov/issue/review-healthcare-failure-mode-and-effects-analysis-hfmea-radiotherapy https

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41959/psn-pdf
    January 16, 2013 - Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards … Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards … https://psnet.ahrq.gov/issue/use-fmea-analysis-reduce-risk-errors-prescribing-and-administering-drugs … - paediatric-wards Failure mode and effect analysis identified calculation errors as a major source … https://psnet.ahrq.gov/issue/use-fmea-analysis-reduce-risk-errors-prescribing-and-administering-drugs-paediatric-wards

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44409/psn-pdf
    January 22, 2016 - Qualitative analysis exploring the functions of questions during end of shift handoffs. … Qualitative analysis exploring the functions of questions during end of shift handoffs. … https://psnet.ahrq.gov/issue/anybody-list-youre-more-worried-about-qualitative-analysis-exploring- functions-questions … This qualitative analysis of verbal handoffs within physician dyads and within nurse dyads found that … https://psnet.ahrq.gov/issue/anybody-list-youre-more-worried-about-qualitative-analysis-exploring-functions-questions

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39331/psn-pdf
    March 03, 2010 - Meta-analysis: effect of interactive communication between collaborating primary care physicians and … Meta-analysis: effect of interactive communication between collaborating primary care physicians and … https://psnet.ahrq.gov/issue/meta-analysis-effect-interactive-communication-between-collaborating- primary-care-physicians … This meta-analysis found that interactive communication between collaborating primary care providers … https://psnet.ahrq.gov/issue/meta-analysis-effect-interactive-communication-between-collaborating-primary-care-physicians
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