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Showing results for "culture of safety".

9921. Unintended Consequences of CPOE | PSNet
      psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
      September 01, 2004 - The cultures from her peritoneal fluid grew multiple bacterial species, raising concerns for bowel perforation … of recommendations in 1999 ( 1 ), even before patient safety catapulted into the spotlight following … Patient Safety Primer: Computerized Provider Order Entry. AHRQ Patient Safety Network. … Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. 2nd ed. … Safety-I and Safety-II: The Past and Future of Safety Management. Farnham, UK: Ashgate; 2014.

9922. Waiting Too Long | PSNet
      psnet.ahrq.gov/web-mm/waiting-too-long
      February 01, 2013 - times of average census. … Perspective Are We Getting Better at Measuring Patient Safety … July 31, 2013 Identifying organizational cultures that promote patient safety. … Related Resources Annual Perspective Equity in Patient Safety … Schuelke about Virtual Nursing August 30, 2023 Perspectives on Safety

9923. Inadequate Preanesthetic Evaluation, Airway Trouble | PSNet
      psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
      November 01, 2023 - technical and systems advances in safety, such as better access to advanced airway devices, greater … found to be 0.4% of 176,679 adult cases.( 8 ) The Difficult Airway Algorithm emphasizes the safety advantage … The patient safety benefit of performing the evaluation prior to the day of surgery has resulted in the … Points Difficult mask ventilation and intubation are critical safety events; loss of control of … Culture: Principles, Practices, and Pragmatic Approaches.

9924. Mother's Milk, but Whose Mother? | PSNet
      psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
      November 15, 2023 - bin for infants' milk.( 1 ) While these implementations address quality assurance and patient safety … reliable technological systems if the processes and culture are not strong.( 15 ) Take-Home Points … Computerization can create safety hazards: a bar-coding near miss. … September 9, 2015 Patient safety: threats and solutions. … Perspective Surveillance Monitoring to Improve Patient Safety

9925. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! | PSNet
      psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
      February 01, 2023 - medical illness, poor fluid and food intake, and relative insulin deficiency. 7,8 Approach to Improving Safety … & Patient Safety Target Studies have shown that patients with diabetes mellitus on any SGLT2i have an … Endocr Pract . 2022;28(9):884-888. [ Free full text ] Drug Safety Communication. … March 21, 2018 A mixed methods study exploring patient safety culture at 4 VHA Hospitals … October 2, 2024 Perspective Medical Scribes and Patient Safety

9926. In Conversation With… Enrico Coiera, MB, BS, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd
      February 01, 2014 - patient safety? … We have this culture such that people are hypersensitive about interrupting someone, but somebody needs … Challenges in measuring the impact of interruption on patient safety and workflow outcomes. … ISMP Medication Safety Alert! Acute Care Edition. Side tracks on the safety express. … No interruptions please: impact of a No Interruption Zone on medication safety in intensive care units

9927. Transition to Nowhere | PSNet
      psnet.ahrq.gov/web-mm/transition-nowhere
      March 21, 2009 - Busy inpatient teams are unlikely to have time to assess and address all of these areas at the time of … New models of care, including the Patient-Centered Medical Home (PCMH), and new types of health care … Division of Geriatrics, University of Utah School of Medicine    Acknowledgements The author wishes … Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists … 2003 Perspective Establishing a Safety Culture:

9928. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33664/psn-pdf
      March 01, 2008 - RW: What data do you have that demonstrate that in fact this improves patient safety? … RW: Is the feeling of the organization that the evidence of safety benefit is so self-evident and impressive … data to make the case for patient safety? … Not necessarily from a patient safety standpoint, but we have found that the decision of whether a line … four blood cultures is positive at 48 hours.

9929. Delayed Breast Cancer Diagnosis: A False Sense of Security. | PSNet
      psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
      May 01, 2005 - Did the culture in the organization encourage consultation and provide support for new clinicians? … Research and Practice, and the State of Massachusetts Betsy Lehman Center for Patient Safety, contributes … Patient Safety and Quality Healthcare; 2015. … Ambulatory safety nets to reduce missed and delayed diagnoses of cancer. … Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

9930. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49556/psn-pdf
      March 01, 2008 - According to the Pennsylvania Patient Safety Reporting System (PA-PSRS), the most common classes of … PA-PSRS Patient Safety Advisory. March 2006;3:33-34. … Cultural diversity and medication safety. ISMP Medication Safety Alert! Acute Care Edition. … ISMP Medication Safety Alert! Acute Care Edition. November 1, 2000. … National Patient Safety Goals. Joint Commission Web site.

9931. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.128_slideshow.ppt
      July 01, 2006 - current transport practice and policies Propose interventions that might improve safety of intrahospital … cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10146115 Improving the Safety of Intrahospital Transport … Are there special safety hazards in any of the units (eg, MRI magnets)? … What level of training and competency assessment is done related to patient safety during transport? … Assess Current Practice: Handoff Communication How are the patient’s condition, potential safety risks

9932. Premature or Overdue? | PSNet
      psnet.ahrq.gov/web-mm/premature-or-overdue
      December 23, 2020 - gestational age depends on a calculated composite of measures of fetal parts. … October 20, 2021 WebM&M Cases Culture Clash No More: … safety in team communication. … Related Resources Annual Perspective Improving Diagnostic Safety … Perinatal Health Through Quality, Safety and Performance Initiatives (TIOP III).

9933. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33847/psn-pdf
      August 01, 2017 - Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwestern University … with him about quality and safety in surgery. … Wachter: Surgeons have always cared deeply about their quality and safety and their outcomes, but they … The best evidence for how our culture has changed in surgery has been that whenever we now put forth … We definitely have evolved in both the safety and quality areas and hopefully to some degree are perceived

9934. In Conversation with…Vineet Arora, MD, MA | PSNet
      psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma
      March 01, 2011 - I think that's how a lot of us get involved in patient safety, through personal experiences. … Our culture in health care is very different from those other industries that have adopted some effective … I think if there is a yes to any of these questions, there's an inherent increase in your safety risk … What do you think has happened to the safety of handoffs since we first began cutting duty hours? … and Patient Safety.

9935. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. | PSNet
      psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
      October 28, 2020 - She was diagnosed as having either “mono-spot negative mononucleosis” or “culture-negative and ASO-negative … adrenal crisis is fatal. 7 Approach to Optimize Patient Safety This case highlights the challenge of … October 28, 2020 Perspective Reducing the Safety … January 18, 2023 Impact of the Agency for Healthcare Research and Quality's Safety Program … evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient

9936. In Conversation With... Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
      May 14, 2020 - However, the overall safety of telehealth is less well studied. … Its expanded use has served as a means of ensuring the safety of both patients and frontline providers … safety outcomes. … It is important for institutions to maintain good patient safety culture and ensure that providers have … safety.

9937. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33806/psn-pdf
      April 01, 2016 - these changes on patient outcomes and safety. … might https://psnet.ahrq.gov/issue/teamstepps-strategies-and-tools-enhance-performance-and-patient-safety … affect the amount of time they were spending in front of a computer, the amount of time in contact … https://psnet.ahrq.gov/issue/surgical-safety-checklist-reduce-morbidity-and-mortality-global-population … The infrastructure of this ongoing project has allowed us to take all of the components of the I-PASS

9938. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.161_slideshow.ppt
      October 01, 2007 - Physical examination revealed an oxygen saturation level of 98%, normal blood pressure, heart rate of … Competencies This case identifies intertwined failures in four physician competencies that affect patient safety … The role of teamwork in professional education of physicians: current status and assessment of recommendations … quality care and collegial work relationships Culture of “no blame” and system responsibility for safety … National Board of Medical Examiners. Assessment of Professional Behaviors.

9939. Multiple Levels Involved in Prescribing the Wrong Medication | PSNet
      psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
      December 23, 2020 - In the Swiss Cheese Model, each “slice” of “cheese” represents a measure taken to enhance patient safety … patient safety work is to continue to add “slices” of safety measures to reduce the size of the “holes …  patient safety. … World Health Organization: Patients for Patient Safety.  … Care Status December 23, 2020 WebM&M Cases Culture

9940. Updates in the Management of High-Risk Pulmonary Embolism | PSNet
      psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
      December 02, 2020 - The use of standardized handoff tools has been shown to decrease adverse events and improve safety.( … Lawrence Center for Quality and Safety Assistant Professor of Emergency Medicine, Harvard Medical School … , 2017 Morbidity and mortality conference in emergency medicine residencies and the culture … of safety. … 1, 2018 View More Related Resources Patient Safety