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Showing results for "discussion".

1781. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46349/psn-pdf
      August 16, 2017 - Health Literacy Tools for Providers of Medication Therapy Management. August 16, 2017 Rockville, MD: Agency for Healthcare Research and Quality; July 2017. https://psnet.ahrq.gov/issue/health-literacy-tools-providers-medication-therapy-management Health literacy is important for effective care communications and s…

1782. Getting to the Root of the Matter | PSNet
      psnet.ahrq.gov/web-mm/getting-root-matter
      September 01, 2005 - A full discussion of issues related to the human factors and teamwork problems in this case is beyond

1783. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34650/psn-pdf
      April 21, 2015 - Human error: models and management. April 21, 2015 Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770. https://psnet.ahrq.gov/issue/human-error-models-and-management The author discusses concepts of human error, contrasting the person approach with a system approach in understanding the diff…

1784. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46988/psn-pdf
      April 25, 2018 - Opioid Stewardship. April 25, 2018 Ochsner J. 2018;18(1):20-45. https://psnet.ahrq.gov/issue/opioid-stewardship Both organizational and national strategies are required to reduce opioid-related harm. This special issue section explores one health system's efforts to address the opioid epidemic. Articles discuss em…

1785. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43342/psn-pdf
      July 16, 2014 - Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool. July 16, 2014 Chapman SM, Fitzsimons J, Davey N, et al. Prevalence and severity of patient harm in a sample of UK- hospitalised children detected by the Paediatric Trigger Tool. BMJ Open. 2014;4…

1786. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35220/psn-pdf
      May 14, 2015 - Patient Safety and Quality Improvement Act of 2005. May 14, 2015 Pub L No. 109-41.  https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005 This bill amends the Public Health Service Act to encourage a culture of safety in health care organizations. The bill, signed into law July 29, 2005…

1787. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43438/psn-pdf
      February 23, 2018 - Safety-I and Safety-II: The Past and Future of Safety Management. February 23, 2018 Hollnagel E. Aldershot, Hampshire, England: Ashgate; 2014. ISBN: 9781472423085. https://psnet.ahrq.gov/issue/safety-i-and-safety-ii-past-and-future-safety-management Historically, the approach to patient safety has been more reacti…

1788. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41796/psn-pdf
      January 18, 2013 - Retained surgical items: a problem yet to be solved. January 18, 2013 Stawicki SPA, Moffatt-Bruce SD, Ahmed HM, et al. Retained surgical items: a problem yet to be solved. J Am Coll Surg. 2013;216(1):15-22. doi:10.1016/j.jamcollsurg.2012.08.026. https://psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-so…

1789. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43309/psn-pdf
      August 02, 2015 - Wrong-side thoracentesis: lessons learned from root cause analysis. August 2, 2015 Miller K, Mims M, Paull DE, et al. Wrong-side thoracentesis: lessons learned from root cause analysis. JAMA Surg. 2014;149(8):774-9. doi:10.1001/jamasurg.2014.146. https://psnet.ahrq.gov/issue/wrong-side-thoracentesis-lessons-learne…

1790. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45117/psn-pdf
      August 03, 2016 - Using computerized prescriber order entry to limit overrides from automated dispensing cabinets. August 3, 2016 Drake E, Srinivas P, Trujillo T. Using computerized prescriber order entry to limit overrides from automated dispensing cabinets. Am J Health-Syst Pharm. 2016;73(14):1033-1035. doi:10.2146/ajhp150564. ht…

1791. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42669/psn-pdf
      September 27, 2017 - Patient-reported missed nursing care correlated with adverse events. September 27, 2017 Kalisch BJ, Xie B, Dabney BW. Patient-reported missed nursing care correlated with adverse events. Am J Med Qual. 2014;29(5):415-22. doi:10.1177/1062860613501715. https://psnet.ahrq.gov/issue/patient-reported-missed-nursing-car…

1792. A Seasonal Care Transition Failure | PSNet
      psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
      June 01, 2016 - After discussion, the provider sent off a prostate-specific antigen (PSA) test to screen the patient

1793. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps | PSNet
      psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
      April 24, 2018 - on biopsy, is not consistently recommended based on numerous large trials. 3-5 This is an important discussion

1794. Managing Ascites: Hazards of Fluid Removal | PSNet
      psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
      June 01, 2018 - While there was discussion about "how much to take off," the patient became acutely hypotensive as the

1795. Crossed Coverage | PSNet
      psnet.ahrq.gov/web-mm/crossed-coverage
      September 01, 2015 - although alerts related to warfarin were the most likely to result in an action).( 10 ) In the case under discussion

1796. Electronic Err | PSNet
      psnet.ahrq.gov/web-mm/electronic-err
      April 01, 2014 - The Institution's Response After a discussion of this case at the clinic's monthly safety and quality

1797. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40673/psn-pdf
      September 03, 2011 - Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units. September 3, 2011 Mayer CM, Cluff L, Lin W-T, et al. Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units. Jt Comm J Qual Patient Saf. 2011;37(8):365-374. htt…

1798. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46766/psn-pdf
      January 17, 2018 - What hinders the uptake of computerized decision support systems in hospitals? A qualitative study and framework for implementation. January 17, 2018 Liberati EG, Ruggiero F, Galuppo L, et al. What hinders the uptake of computerized decision support systems in hospitals? A qualitative study and framework for imple…

1799. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39523/psn-pdf
      September 26, 2016 - Association of interruptions with an increased risk and severity of medication administration errors. September 26, 2016 Westbrook JI, Woods A, Rob MI, et al. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683-690. doi:10.1001/arch…

1800. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45666/psn-pdf
      April 24, 2018 - The relationship between professional burnout and quality and safety in healthcare: a meta-analysis. April 24, 2018 Salyers MP, Bonfils KA, Luther L, et al. The Relationship Between Professional Burnout and Quality and Safety in Healthcare: A Meta-Analysis. J Gen Intern Care. 2017;32(4):475-482. doi:10.1007/s11606-…