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Showing results for "discussion".

  1. Swiss Cheese Model | PSNet

    psnet.ahrq.gov/glossary/swiss-cheese-model
    September 13, 2021 - Swiss Cheese Model September 13, 2021 Anonymous (not verified) Reason developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. In the model, each slice of cheese represents a safe…

  2. AORN Position Statement on Patient Safety. | PSNet

    psnet.ahrq.gov/issue/aorn-position-statement-patient-safety
    May 20, 2020 - Organizational Policy/Guidelines AORN Position Statement on Patient Safety. Citation Text: AORN Position Statement on Patient Safety. AORN J. 2022;115(5):454-457. doi:10.1002/aorn.13671. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…

  3. 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…

  4. 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…

  5. 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…

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50610/psn-pdf
    October 30, 2019 - First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit October 30, 2019 Profit J, Scheid A, Ridout E. First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safe…

  12. 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…

  13. 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…

  14. 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…

  15. 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-…

  16. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety | PSNet

    psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
    October 01, 2009 - dies of a medical mistake, partly due to lax resident supervision New York Hospital 1984 Public discussion

  17. Operationalizing Patient Safety at Academic Medical Centers | PSNet

    psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
    August 01, 2010 - Second, trainees must improve their communication skills as they relate to discussion of medical mistakes

  18. Palliative Care: Comfort vs. Harm | PSNet

    psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
    December 04, 2016 - SPOTLIGHT CASE Palliative Care: Comfort vs. Harm Citation Text: Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndN…

  19. Isolated Clot, Real Error | PSNet

    psnet.ahrq.gov/web-mm/isolated-clot-real-error
    December 01, 2013 - high-quality evidence in specific situations as well as variation in patient preference, we hope this discussion

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45167/psn-pdf
    May 25, 2016 - AHRQ Communication and Optimal Resolution (CANDOR) Toolkit. May 25, 2016 Rockville, MD: Agency for Healthcare Research and Quality; May 2016. https://psnet.ahrq.gov/issue/ahrq-communication-and-optimal-resolution-candor-toolkit Traditionally, health systems have disclosed adverse events to patients only through a …
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