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psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk
Citation Text:
Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quali…
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psnet.ahrq.gov/node/867359/psn-pdf
December 18, 2024 - Importance of Following Safe Practices for Infant Feeding
and Handling Expressed Breast Milk
December 18, 2024
Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling
Expressed Breast Milk. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/importance-following-saf…
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…
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psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
July 01, 2012 - ), almost all residents reported having accidently entered orders in the wrong patient's electronic chart … While these house officers uniformly reported catching their errors before closing the electronic chart … For example, data displayed in the chart are usually without additional identifying information such … Points Medical informaticists have focused on demonstrating EMRs' many advantages over paper patient charts
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psnet.ahrq.gov/issue/life-error-little-slips-big-disasters
October 04, 2017 - December 6, 2013
The contribution of prescription chart design and familiarity to prescribing
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psnet.ahrq.gov/issue/quality-work-environments-nurse-and-patient-safety
December 18, 2018 - Book/Report
Quality Work Environments for Nurse and Patient Safety.
Citation Text:
Quality Work Environments for Nurse and Patient Safety. McGillis Hall L. Sudbury, MA: Jones and Bartlett Publishers; 2005. ISBN 9780763728809.
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psnet.ahrq.gov/issue/aviations-gift-health-care
December 19, 2018 - Newspaper/Magazine Article
Aviation's gift to health care.
Citation Text:
Aviation's gift to health care. Nance JJ.
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psnet.ahrq.gov/issue/identifying-and-preventing-medication-errors
September 29, 2017 - Multi-use Website
Identifying and Preventing Medication Errors.
Citation Text:
Identifying and Preventing Medication Errors. Institute of Medicine; IOM
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.140_slideshow.ppt
December 01, 2006 - She was treated with argatroban, and it was noted on the chart that the patient should receive no further … A thorough review of the chart and hemodialysis records revealed that during this second hospitalization … been repeatedly exposed to heparin during dialysis sessions, despite her recent history of HIT and the chart
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psnet.ahrq.gov/web-mm/carpe-diem-seize-day
September 01, 2012 - This discussion with the patient should be documented in the chart. … As my legal colleagues remind me, "If it is not written in the chart, it never happened." … In addition, I specifically inform the patient and document in the chart that I advised him to stop driving
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psnet.ahrq.gov/node/49604/psn-pdf
June 01, 2010 - The anesthesiologist and neurosurgeon both clearly documented the plan of care in the
chart. … The on-call anesthesiologist did not review the patient's chart or obtain
any further information. … These last two tasks would necessitate a chart
review and further investigation that could have potentially
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psnet.ahrq.gov/issue/wristband-color-standardization
October 25, 2013 - September 28, 2022
Reliability and usability of a 7-minute chart review tool to identify
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.33_slideshow.ppt
October 01, 2003 - After the patient was intubated for general anesthesia, the trainee reviewed her chart and noted that … Case (cont.): Wrong Side Surgery
The trainee informed the attending that he had just reviewed the chart
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
July 01, 2003 - As there was no DNR form in the chart, the nurse called a code and CPR was initiated. … The Code Status Dilemma
Documentation—No code status documented in chart; therefore, code initiated
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psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
January 01, 2018 - As you remember, there was only one physical chart. … If that happened to be downstairs in radiology with the patient, you couldn't see that chart. … of the downsides of the electronic medical record, we would never want to go back because the paper chart … Because they think, "For any new readers or consultants reading the chart today, I want them to know … People now are getting used to the idea that the chart will contain a mix of fiction and nonfiction.
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psnet.ahrq.gov/issue/computerized-medication-order-errors-studied
March 26, 2014 - Preventable and non-preventable adverse drug events in hospitalized patients: a prospective chart
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psnet.ahrq.gov/issue/reducing-diagnostic-errors-0
May 09, 2018 - Patient Safety Innovations
The e-Autopsy/e-Biopsy: A Systematic Chart
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psnet.ahrq.gov/issue/medical-error-reporting-system-still-year
July 10, 2013 - April 20, 2022
Reliability and usability of a 7-minute chart review tool to identify
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psnet.ahrq.gov/issue/variation-patient-safety-outcomes-and-importance-being-informed
July 02, 2014 - September 12, 2012
Reliability and usability of a 7-minute chart review tool to identify
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psnet.ahrq.gov/issue/patient-safety-and-satisfaction-state-american-hospitals
July 02, 2014 - October 25, 2013
Reliability and usability of a 7-minute chart review tool to identify