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Showing results for "culture of safety".

9941. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event | PSNet
      psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
      July 01, 2017 - transfusion recipient safety. … The Commentary By Sarah Barnhard, MD Introduction: Transfusion Safety The history of the blood supply … in safety in terms of infectious agents. 1 Rates of transfusion-transmitted viral infections such as … Emily Cooley Lecture 2002: Transfusion safety in the hospital. … a Positive Blood Culture July 1, 2017 WebM&M Cases

9942. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
      January 01, 2024 - In today’s hospital culture, no patient should suffer as a result of reluctance of nurses, physicians … Patient Safety Over Power Hierarchy: A Scoping Review of Healthcare Professionals' Speaking-up Skills … AHRQ Patient Safety Network (PSNet). October 31, 2023. Accessed July 15, 2024. … Patient Safety Issues From Information Overload in Electronic Medical Records.  … [Free full text] Advancing safety with closed-loop communication of test results. Quick Safety.

9943. Novel Drug Misuse | PSNet
      psnet.ahrq.gov/web-mm/novel-drug-misuse
      September 30, 2010 - patients with sepsis but low risk of death (ADDRESS) was recently stopped by the Data Safety and Monitoring … Efficacy and safety of recombinant human activated protein C for severe sepsis. … diagnostic safety. … culture and less caregiver burnout. … July 3, 2016 Safety climate, safety climate strength, and length of stay in the NICU.

9944. Palliative Care: Comfort vs. Harm | PSNet
      psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
      December 04, 2016 - Medical errors and patient safety in palliative care: a review of current literature. … December 4, 2016 Medical errors and patient safety in palliative care: a review of current … Patients' perception of safety while receiving specialist community palliative care. … December 21, 2022 WebM&M Cases Culture Clash No More: … December 4, 2016 Patients' and families' perspectives of patient safety at the end of

9945. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49785/psn-pdf
      February 01, 2017 - Good team communication is a critical element of patient safety and should be an ongoing priority for … might facilitate or create barriers for good communication and safety. … [Available at] https://archive.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources … Patient Safety and Quality: An Evidence-Based Handbook for Nurses. … The role of consumers, families and the community in patient safety: learning from experience.

9946. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk | PSNet
      psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
      January 31, 2024 - The whole batch of formula was discarded, and a safety report was filed.   … as well as ensuring a strong patient safety culture are essential. … Approaches to Improving Safety Standardized Processes for Infant Feeding Expressed breast milk being … of expressed breast milk. 20 The Pennsylvania Patient Safety Authority described a comprehensive set … Best practices for communicating after patient safety errors have occurred may include the following:

9947. Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner | PSNet
      psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
      February 26, 2025 - . 2 Although many anesthesia providers are pioneers in the field of patient safety, errors and adverse … , the NAPA Anesthesia Patient Safety Institute (NAPSI). … The critical care safety study: the incidence and nature of adverse events and serious medical errors … surgical safety checklist (SSC): an integrative review. … August 30, 2023 Patient Safety Innovations Ambulatory Safety

9948. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33730/psn-pdf
      June 01, 2012 - He is Director of the Imperial Centre for Patient Safety and Service Quality and the Clinical Safety … He is the editor of Clinical Risk Management and author of the book Patient Safety. … Robert Wachter, Editor, AHRQ WebM&M: As you entered the field of patient safety a couple of decades … It's one of the areas of safety where a big national system has had a major impact because there has … contribution of people like you—from nonproviders looking at safety.

9949. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33760/psn-pdf
      February 01, 2014 - spoke with him about how interruptions and distractions in the clinical environment influence patient safety … patient safety? … decade that in some clinical settings, not only are interruptions frequent but they're also a patient safety … There are lots of ways of doing it. … We have this culture such that people are hypersensitive about interrupting someone, but somebody needs

9950. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33673/psn-pdf
      September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety September 1, 2008 Rothschild JM, Keohane C. … The Role of Bar Coding and Smart Pumps in Safety. PSNet [internet]. 2008. … https://psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety Perspective Medication safety … medication safety: getting the right dose of the right drug to the right patient using the right route … A controlled trial of smart infusion pumps to improve medication safety in critically ill patients.

9951. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50842/psn-pdf
      January 29, 2020 - One report states that 11% of preventable adverse patient safety outcomes are a result of ineffective … A joint ED/Radiology workgroup to explore ways to improve the safety and efficiency of transport between … A joint Radiology/ED workgroup, established to improve coordination, communication, and safety of transport … Interruptions of nurses' activities and patient safety: an integrative literature review. … WHO Collaborating Centre on Patient Safety Solutions: Patient Identification.  May 2007.  

9952. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867359/psn-pdf
      December 18, 2024 - The whole batch of formula was discarded, and a safety report was filed.   … must be in place to ensure safety when administering breast milk to patients.14 When expressed breast … staffing as well as ensuring a strong patient safety culture are essential. … Approaches to Improving Safety Standardized Processes for Infant Feeding Expressed breast milk being … of expressed breast milk.20 The Pennsylvania Patient Safety Authority described a comprehensive set

9953. Missed CANDOR Implementation Opportunities. | PSNet
      psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
      November 11, 2020 - After this case was reviewed by the patient safety committee several months after the operation; potential … Initiate the resolution process, which includes implementing patient safety processes to improve care … As the quality and safety review and determination of a settlement offer take a significant amount of … Paving the Way for Progress: The Agency for Healthcare Research and Quality Patient Safety and Medical … November 11, 2020 Culture change in infection control: applying psychological principles

9954. Health Care Delivery and Pharmacists During the COVID-19 Pandemic | PSNet
      psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic
      June 29, 2020 - and the prevention of medication errors is always one of several priority safety concerns for pharmacists … Lastly, redeployment of healthcare personnel to new areas and specialty of care may introduce safety … ensure the safety of all staff and the patients they are interacting with.  … I credit the culture shift over the last 20 years to make sure that patient safety remains front and … Then the safe use of those medications, as we were just talking about – ensuring safety of those medications

9955. In Conversation With... Freya Spielberg, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
      September 28, 2022 - A narrow view of patient safety is if you, for example, give the wrong medicines to someone and they … However, it'll take a change in the culture because we’re so used to the idea that care is provided within … AHRQ’s broad definition of patient safety includes “prevention of diagnostic errors, medical errors … A patient safety event can be the furthest downstream outcome of a series of events that starts with … Medicine—and all of the models have distinct implications for patient safety.

9956. Telemedicine and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/telemedicine-and-patient-safety
      September 01, 2016 - On top of that, many of these applications are marketed directly to consumers without any formal safety … all phases of the telemedicine project life cycle; (ii) integrate safety testing as part of usability … safety. … The impact of telehealthcare on the quality and safety of care: a systematic overview. … safety.

9957. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49527/psn-pdf
      December 01, 2006 - Examples of ongoing Q tracks programs include monitoring errors in patient wristbands, blood culture … Chief, Laboratory Errors and Patient Safety Newsletter University of Washington, Department of Laboratory … Errors in laboratory medicine: practical lessons to improve patient safety. … Putting power into patient safety interventions. Lab Errors Patient Saf. 2005;1:9–11. 15. … Tangible involvement and action by leadership in support of patient safety Regular communication (lectures

9958. In Conversation with…Pat Croskerry, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
      June 01, 2010 - reflect your interest in safety and that you're particularly proud of? … It's been helped by the patient safety movement of course. … How did you get the culture to accept that? PC: It wasn't easy. … safety problems. … Model of Patient Safety.

9959. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
      March 01, 2009 - handoff guidelines described by the Joint Commission See Notes for references. 2008 National Patient Safety … The Joint Commission Accreditation Program: Ambulatory Health Care National Patient Safety Goals. … information fails to be conveyed or is forgotten See Notes for references. 2008 National Patient Safety … The Joint Commission Accreditation Program: Ambulatory Health Care National Patient Safety Goals. … and include the following items (see next slide) See Notes for reference. 2008 National Patient Safety

9960. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61078/psn-pdf
      October 28, 2020 - can be safely utilized in an inpatient setting  Discuss recommended practices to optimize patient safety … of incorrect management related to use of her home CGM for calculation of insulin doses.  … and providers, and the need for standardized hospital protocols.4,6  Approach to Optimizing Patient Safety … on clinical outcomes and safety to recommend widespread CGM use in hospitalized patients.22,23 Even … An Overview of Safety Issues on Use of Insulin Pumps and Continuous Glucose Monitoring Systems in the