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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/848381/psn-pdfMay 03, 2023 - VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout. May 3, 2023 Muoio D. Fierce Healthcare. April 21, 2023. https://psnet.ahrq.gov/issue/va-pauses-16b-oracle-cerner-ehr-deployments-indefinitely-address-error- ridden-early-rollout Notable problems have occurred during t… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37468/psn-pdfApril 11, 2011 - Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes. April 11, 2011 Hunt EA, Walker AR, Shaffner DH, et al. Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the fir… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/846447/psn-pdfMarch 22, 2023 - Prosocial voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents. March 22, 2023 Richmond JG, Burgess N. Prosocial voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents. J Health Organ Manag. 2023;37(… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45021/psn-pdfApril 06, 2016 - Scandal as a sentinel event—recognizing hidden cost–quality trade-offs. April 6, 2016 Bloche G. Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. N Engl J Med. 2016;374(11):1001-3. doi:10.1056/NEJMp1502629. https://psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-t… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45699/psn-pdfDecember 21, 2016 - Towards a new paradigm in laboratory medicine: the five rights. December 21, 2016 Plebani M. Towards a new paradigm in laboratory medicine: the five rights. Clin Chem Lab Med. 2016;54(12):1881-1891. doi:10.1515/cclm-2016-0848. https://psnet.ahrq.gov/issue/towards-new-paradigm-laboratory-medicine-five-rights Error… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37585/psn-pdfApril 29, 2010 - Medication errors involving patient-controlled analgesia. April 29, 2010 Hicks RW, Sikirica V, Nelson W, et al. Medication errors involving patient-controlled analgesia. Am J Health Syst Pharm. 2008;65(5):429-40. doi:10.2146/ajhp070194. https://psnet.ahrq.gov/issue/medication-errors-involving-patient-controlled-a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35448/psn-pdfSeptember 18, 2009 - Relationship between performance measurement and accreditation: implications for quality of care and patient safety. September 18, 2009 Miller MR, Pronovost P, Donithan M, et al. Relationship between performance measurement and accreditation: implications for quality of care and patient safety. Am J Med Qual. 2005… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41045/psn-pdfJuly 02, 2014 - Relating faults in diagnostic reasoning with diagnostic errors and patient harm. July 2, 2014 Zwaan L, Thijs A, Wagner C, et al. Relating faults in diagnostic reasoning with diagnostic errors and patient harm. Acad Med. 2012;87(2):149-156. doi:10.1097/ACM.0b013e31823f71e6. https://psnet.ahrq.gov/issue/relating-fau… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45594/psn-pdfDecember 19, 2017 - Teaching quality improvement and patient safety in residency education: strategies for meaningful resident quality and safety initiatives. December 19, 2017 Morrison RJ, Bowe SN, Brenner MJ. Teaching Quality Improvement and Patient Safety in Residency Education: Strategies for Meaningful Resident Quality and Safet… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44886/psn-pdfSeptember 27, 2016 - Direct oral anticoagulants: new drugs with practical problems. How can nurses help prevent patient harm? September 27, 2016 Barras MA, Hughes D, Ullner M. Direct oral anticoagulants: New drugs with practical problems. How can nurses help prevent patient harm? Nurs Health Sci. 2016;18(3):408-11. doi:10.1111/nhs.1226… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73157/psn-pdfApril 21, 2021 - The impact of power on health care team performance and patient safety: a review of the literature. April 21, 2021 Stevens EL, Hulme A, Salmon PM. The impact of power on health care team performance and patient safety: a review of the literature. Ergonomics. 2021;64(8):1072-1090. doi:10.1080/00140139.2021.1906454.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/851061/psn-pdfJune 28, 2023 - Learning from experience: a qualitative study of surgeons' perspectives on reporting and dealing with serious adverse events. June 28, 2023 Øyri SF, Søreide K, Søreide E, et al. Learning from experience: a qualitative study of surgeons’ perspectives on reporting and dealing with serious adverse events. BMJ Open Qu… -
Identifying Delirium (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/identifying-delirium.pdfJune 01, 2021 - Identifying Delirium IDENTIFYING DELIRIUM ABCs OF IDENTIFICATION Acute/subacute • Altered mental status with change in attention Behavioral disturbance • (Restless, agitated, combative) Changes in consciousness • (Jittery, drowsy, difficult to arouse) COMMON CAUSES OF DELIRIUM COMMON… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72549/psn-pdfDecember 09, 2020 - Pharmacist counseling when dispensing naloxone by standing order: a secret shopper study of 4 chain pharmacies. December 9, 2020 Contreras J, Baus C, Brandt C, et al. Pharmacist counseling when dispensing naloxone by standing order: a secret shopper study of 4 chain pharmacies. J Am Pharm Assoc (2003). 2021;61(2):… -
www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/improve/teams-infographic.htmlMarch 01, 2017 - T.E.A.M.S. infographic AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Culture consists of values, attitudes, and beliefs that can have an impact on resident safety, care outcomes, and staff satisfaction. Culture influences how change can occur. T Team Formation The most effective…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35752/psn-pdfDecember 23, 2012 - Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. December 23, 2012 Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Ann Intern Med. 2002;137(5 Part 1):327-333. ht… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/861288/psn-pdfJanuary 24, 2024 - The impact of rationing nursing care on patient safety: a systematic review. January 24, 2024 Uchmanowicz I, Lisiak M, Wleklik M, et al. The impact of rationing nursing care on patient safety: a systematic review. Med Sci Monit. 2024;30:e942031. doi:10.12659/msm.942031. https://psnet.ahrq.gov/issue/impact-rationin… -
CAHPS 101 (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-101-webcast-01-fry-intro.pdfJanuary 08, 2019 - CAHPS 101 Understanding CAHPS® Surveys: A Primer for New Users A Webcast Presented by the AHRQ CAHPS User Network January 8, 2019 12:00 – 1:00 pm ET Need Help? • No sound from computer speakers? • Trouble with your connection or slides not moving? • Log out and log back in • Other problems? ► Use Q&A fea… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44390/psn-pdfJuly 18, 2016 - Should medical errors be disclosed to pediatric patients? Pediatricians' attitudes toward error disclosure. July 18, 2016 Kolaitis IN, Schinasi DA, Ross LF. Should Medical Errors Be Disclosed to Pediatric Patients? Pediatricians' Attitudes Toward Error Disclosure. Acad Pediatr. 2016;16(5):482-488. doi:10.1016/j.aca… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47654/psn-pdfFebruary 27, 2019 - The Swiss Cheese Conference: integrating and aligning quality improvement education with hospital patient safety initiatives. February 27, 2019 Durstenfeld MS, Statman S, Dikman A, et al. The Swiss Cheese Conference: integrating and aligning quality improvement education with hospital patient safety initiatives. A…
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