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1821. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40283/psn-pdf
      February 15, 2017 - Principles of Risk Management and Patient Safety. February 15, 2017 Youngberg BJ, ed. Sudbury, MA: Jones Bartlett; 2011. ISBN: 9780763774059. https://psnet.ahrq.gov/issue/principles-risk-management-and-patient-safety This textbook discusses claims management, risk financing, and proactive risk reduction within the …

1822. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38268/psn-pdf
      December 03, 2008 - Anticoagulant safety practices call for pharmacist supervision. December 3, 2008 Scott A. https://psnet.ahrq.gov/issue/anticoagulant-safety-practices-call-pharmacist-supervision This article discusses hospital efforts to respond to the Joint Commission sentinel event alert regarding anticoagulants and highlights …

1823. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39307/psn-pdf
      February 24, 2010 - Intimidation: a concept analysis. February 24, 2010 Lamontagne C. Intimidation: a concept analysis. Nurs Forum. 2010;45(1):54-65. doi:10.1111/j.1744- 6198.2009.00162.x. https://psnet.ahrq.gov/issue/intimidation-concept-analysis This piece discusses intimidation and its relationship to medical errors and patient sa…

1824. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees | PSNet
      psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
      February 22, 2017 - SPOTLIGHT CASE Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees Citation Text: Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…

1825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36818/psn-pdf
      August 26, 2011 - Patient safety in women's health care: a framework for progress. August 26, 2011 Gluck PA. Patient safety in women's health care: a framework for progress. Best Pract Res Clin Obstet Gynaecol. 2007;21(4):525-36. https://psnet.ahrq.gov/issue/patient-safety-womens-health-care-framework-progress The author provides …

1826. Renal Failure Due to Benign Prostatic Hyperplasia | PSNet
      psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia
      February 01, 2004 - More serious complications of BPH include acute urinary retention and, in the case under discussion,

1827. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36984/psn-pdf
      September 14, 2011 - TeamSTEPPS: assuring optimal teamwork in clinical settings. September 14, 2011 Clancy CM, Tornberg DN. TeamSTEPPS: assuring optimal teamwork in clinical settings. Am J Med Qual. 2007;22(3):214-7. https://psnet.ahrq.gov/issue/teamstepps-assuring-optimal-teamwork-clinical-settings The authors discuss the TeamSTEPPS…

1828. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47262/psn-pdf
      August 22, 2018 - The Case for Medication Safety Officers (MSO). August 22, 2018 Horsham, PA: Institute for Safe Medication Practices; 2018. https://psnet.ahrq.gov/issue/case-medication-safety-officers-mso Medication safety is a concern in various settings across an organization. This white paper discusses the role of a medication …

1829. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36860/psn-pdf
      January 20, 2016 - IHI Global Trigger Tool for Measuring Adverse Events. 2nd Edition. January 20, 2016 Griffin FA, Resar RK. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009. https://psnet.ahrq.gov/issue/ihi-global-trigger-tool-measuring-adverse-events-2nd-edition This white paper describ…

1830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41120/psn-pdf
      September 08, 2016 - The impact of anti-infective drug shortages on hospitals in the United States: trends and causes. September 8, 2016 Griffith MM, Gross AE, Sutton SH, et al. The impact of anti-infective drug shortages on hospitals in the United States: trends and causes. Clin Infect Dis. 2012;54(5):684-91. doi:10.1093/cid/cir954. …

1831. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40646/psn-pdf
      July 27, 2011 - Engineering a Learning Healthcare System: A Look at the Future: Workshop Summary. July 27, 2011 Grossmann C, Goolsby WA, Olsen L, McGinnis JM; Institute of Medicine and National Academy of Engineering. Washington, DC: The National Academies Press; 2011. ISBN: 9780309120647. https://psnet.ahrq.gov/issue/engineering…

1832. Medical Mistakes and What Doctors Can Learn From Pilots | PSNet
      psnet.ahrq.gov/training-catalog/medical-mistakes-and-what-doctors-can-learn-pilots
      Medical Mistakes and What Doctors Can Learn From Pilots Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization American Academy of Ophthalmology Even…

1833. 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

1834. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34636/psn-pdf
      June 14, 2011 - The wrong patient. June 14, 2011 Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136(11):826-833. https://psnet.ahrq.gov/issue/wrong-patient This case study describes the events of a patient who underwent an unintended invasive cardiac electrophysiology study. While reviewing the details of the case…

1835. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40955/psn-pdf
      March 08, 2017 - Kaiser Permanente's performance improvement system, part 4: creating a learning organization. March 8, 2017 Schilling L, Dearing JW, Staley P, et al. Kaiser Permanente's performance improvement system, Part 4: Creating a learning organization. Jt Comm J Qual Patient Saf. 2011;37(12):532-43. https://psnet.ahrq.gov/…

1836. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44873/psn-pdf
      March 21, 2016 - Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. March 21, 2016 Cambridge, MA: CRICO Strategies; 2016. https://psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report Communication failures are known to contribute to medical errors. Analyzing more …

1837. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/844060/psn-pdf
      June 01, 2016 - Developing a measure of value in health care. June 1, 2016 Ken Lee KH, Matthew Austin J, Pronovost PJ. Developing a measure of value in health care. Value Health. 2015;19(4):323-325. doi:10.1016/j.jval.2014.12.009. https://psnet.ahrq.gov/issue/developing-measure-value-health-care Value-based healthcare is emerging…

1838. 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…

1839. 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…

1840. 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…