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Showing results for "describes".

21. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43978/psn-pdf
    September 01, 2016 - This intervention study describes how inpatient pharmacists modified alerts on intravenous infusion … A previous AHRQ WebM&M commentary describes consequences of overriding an important alert as a result

22. Clinical Areas | PSNet
    psnet.ahrq.gov/clinical-areas
    March 24, 2025 - Olson, MD | March 25, 2025 This pair of cases describes patients misdiagnosed … Olson, MD | March 25, 2025 This pair of cases describes patients misdiagnosed … This article describes the development of a framework to classify communication errors that contributed … This article describes the development of an audit plan using Tracer methodologies to audit six oncology … This article describes the use of a risk management approach to improve handoffs from the operating room

23. Optimizing smart pump technology by increasing critical safety alerts and reducing clinically insignificant alerts. | PSNet
    psnet.ahrq.gov/issue/optimizing-smart-pump-technology-increasing-critical-safety-alerts-and-reducing-clinically
    February 12, 2014 - This intervention study describes how inpatient pharmacists modified alerts on intravenous infusion pumps … A previous AHRQ WebM&M commentary describes consequences of overriding an important alert as a result

24. Interdisciplinary teamwork | PSNet
    psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
    August 10, 2025 - This commentary describes how the team approach to diagnosis is anchored in patient-centered care and … This article describes a systematic team-based care approach to medication reconciliation implemented … This article describes a systematic team-based care approach to medication reconciliation implemented … This commentary describes how the team approach to diagnosis is anchored in patient-centered care and … An AHRQ WebM&M perspective describes the Veterans Health Administration's medical team training program

25. PSNet Curated Library (pdf file)
    psnet.ahrq.gov/print/pdf/node/838351
    July 01, 2024 - This article describes the various ways evidence is collected based on the diagnostic purpose: optimal … This pair of issue briefs describes how organizations can use patient experience to inform improvements … This commentary describes how the team approach to diagnosis is anchored in patient- centered care and … This article describes the various ways evidence is collected based on the diagnostic purpose: optimal … This commentary describes how the team approach to diagnosis is anchored in patient- centered care and

26. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43697/psn-pdf
    March 26, 2015 - This study describes results from this baseline survey, which revealed key opportunities for improvements … A prior AHRQ WebM&M commentary describes a patient who inadvertently received the wrong chemotherapy

27. Opioid Stewardship | PSNet
    psnet.ahrq.gov/curated-library/opioid-stewardship
    December 15, 2024 - Pharmacist Role in Patient Safety February 21, 2020 This perspective describes … This study describes the development, implementation, and effect of a safe prescribing strategy (TOWER … Facebook Twitter Linkedin Copy URL This perspective describes

28. Sentinel events. In memory of Ben—a case study. | PSNet
    psnet.ahrq.gov/issue/sentinel-events-memory-ben-case-study
    July 01, 2016 - Without focusing on the details of the error, the author describes the investigative process that uncovered … The author describes a collaborative, mutually supportive, systems-oriented approach to safety in place

29. Value and Patient Safety | PSNet
    psnet.ahrq.gov/curated-library/value-and-patient-safety
    October 30, 2019 - This commentary describes how value-based care could improve safety, equity, and the patient-focus of … Annette Scheid, MD; and Erick Ridout, MD | October 30, 2019 This piece describes … This commentary describes how value-based care could improve safety, equity, and the patient-focus of … Examining the literature on costs of unsafe care delivery, this report describes the financial impacts … This study describes the organizational structure used at Johns Hopkins Medicine to prioritize improving

30. Periodic Issue | PSNet
    psnet.ahrq.gov/periodic-issue/periodic-issue-473
    March 25, 2025 - This article describes the development of a classification system for two popular uses of AI in health … This article describes the development of a classification system for two popular uses of AI in health … This article describes the development of Simulation-Debriefing Enhanced Needs Assessment (SDENA) to … Olson, MD | March 25, 2025 This pair of cases describes patients misdiagnosed and treated for migraines … The commentary describes the appropriate evaluation for acute abdominal pain, the importance of imaging

31. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43323/psn-pdf
    January 07, 2015 - This direct observation and interview study in an outpatient pharmacy setting describes changes in practice … A past AHRQ WebM&M commentary describes how a nurse entered an outpatient prescription for the wrong

32. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/44958/psn-pdf
    March 09, 2016 - This article describes a Centers for Medicare and Medicaid Services–funded initiative to improve sepsis … A recent WebM&M commentary describes common errors in the early management of sepsis.

33. PSNet Curated Library (pdf file)
    psnet.ahrq.gov/print/pdf/node/867461
    January 31, 2024 - Patient Safety in Frail Older Patients November 26, 2019 This piece describes patient safety risks when … This article describes one nursing home’s experience adapting the Fall TIPS program for use in their … This article describes the co-creation of an intervention to improve medication safety in Danish nursing … This article describes the co-creation of an intervention to improve medication safety in Danish nursing … This article describes one nursing home’s experience adapting the Fall TIPS program for use in their

34. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/39329/psn-pdf
    September 30, 2015 - In this book, written with Eric Vohr, Pronovost describes how his work was inspired by two deaths from … In earnest and plainspoken prose, he describes the inside story of interventions and studies that have

35. PSNet Curated Library (pdf file)
    psnet.ahrq.gov/print/pdf/node/866984
    January 01, 2020 - This commentary describes how the team approach to diagnosis is anchored in patient- centered care and … This article describes a systematic team-based care approach to medication reconciliation implemented … This article describes the multifaceted response of Dana-Farber Cancer Institute after a highly publicized … This article describes a systematic team-based care approach to medication reconciliation implemented … This commentary describes how the team approach to diagnosis is anchored in patient- centered care and

36. Establishing an international baseline for medication safety in oncology: findings from the 2012 ISMP International Medication Safety Self Assessment for Oncology. | PSNet
    psnet.ahrq.gov/issue/establishing-international-baseline-medication-safety-oncology-findings-2012-ismp
    May 14, 2009 - This study describes results from this baseline survey, which revealed key opportunities for improvements … A prior AHRQ WebM&M commentary describes a patient who inadvertently received the wrong chemotherapy

37. The Sepsis Early Recognition and Response Initiative (SERRI). | PSNet
    psnet.ahrq.gov/issue/sepsis-early-recognition-and-response-initiative-serri
    November 11, 2015 - This article describes a Centers for Medicare and Medicaid Services–funded initiative to improve sepsis … A recent WebM&M commentary describes common errors in the early management of sepsis.

38. Unrealized potential and residual consequences of electronic prescribing on pharmacy workflow in the outpatient pharmacy. | PSNet
    psnet.ahrq.gov/issue/unrealized-potential-and-residual-consequences-electronic-prescribing-pharmacy-workflow
    December 31, 2014 - This direct observation and interview study in an outpatient pharmacy setting describes changes in practice … A past AHRQ WebM&M commentary describes how a nurse entered an outpatient prescription for the wrong

39. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37162/psn-pdf
    June 16, 2019 - /issue/ismp-medication-error-report-analysis-16 This monthly selection of medication error reports describes

40. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37801/psn-pdf
    June 16, 2019 - psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-25 This monthly selection of error reports describes