-
psnet.ahrq.gov/node/44387/psn-pdf
August 19, 2015 - Simulation in Surgical Training and Practice.
August 19, 2015
Brown KM, Paige JT, eds. Surg Clin North Am. 2015;95:695-918.
https://psnet.ahrq.gov/issue/simulation-surgical-training-and-practice
Simulation training is being used more broadly as an educational approach in health care. Articles in this
special issue…
-
psnet.ahrq.gov/node/852700/psn-pdf
August 30, 2023 - I spent many years with both startups and established medical device companies
that were heavily focused … Patricia McGaffigan: The nonprofit IHI was established over 30 years ago. … National-Action-Plan-to-Advance-Patient-Safety.aspx
Patricia McGaffigan: Safer Together: A National Action Plan to Advance Patient Safety was established … The four foundational areas of the National Action Plan were established to reflect this essence.
-
psnet.ahrq.gov/issue/establishing-multi-institutional-quality-and-patient-safety-consortium-collaboration-across
June 24, 2009 - Commentary
Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a community-based medical school.
Citation Text:
Hillman E, Paul J, Neustadt M, et al. Establishing a multi-institutional quality and patient safety consortium: collab…
-
psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - the influx of COVID-19 patients and
protocols has posed a challenge for compliance with other more established … Thinking about established patient safety practices
that you found that were misaligned, or where you … PS: Teammate health and safety became a critical issue, and some of the established patient safety
practices
-
psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - diagnosis of diabetic ketoacidosis (DKA) in a patient with type 1 diabetes; the correct diagnosis was not established … understood; however, proposed explanations include: more admissions for mild DKA (criteria for which were established … Institute a specialized diabetes team for inpatient management along with established criteria for when
-
psnet.ahrq.gov/node/42844/psn-pdf
May 29, 2014 - Does the concept of safety culture help or hinder systems
thinking in safety?
May 29, 2014
Reiman T, Rollenhagen C. Does the concept of safety culture help or hinder systems thinking in safety?
Accid Anal Prev. 2014;68(July):5-15. doi:10.1016/j.aap.2013.10.033.
https://psnet.ahrq.gov/issue/does-concept-safety-cult…
-
psnet.ahrq.gov/node/40000/psn-pdf
November 10, 2017 - Behind Human Error, Second Edition.
November 10, 2017
Woods DD, Dekker S, Cook R, Johannesen L. Boca Raton, FL: CRC Press; 2017. ISBN: 9781317175537.
https://psnet.ahrq.gov/issue/behind-human-error-second-edition
"Human error," the authors of this book argue, is an inherently misleading term. Drawing on the field …
-
psnet.ahrq.gov/node/46069/psn-pdf
February 28, 2018 - Strategies for Creating, Sustaining, and Improving a
Culture of Safety in Health Care, Second Edition.
February 28, 2018
Joint Commission Resources. Oak Brook, IL: Joint Commission; 2017. ISBN: 9781599409474.
https://psnet.ahrq.gov/issue/strategies-creating-sustaining-and-improving-culture-safety-health-care-
seco…
-
psnet.ahrq.gov/issue/establishing-international-baseline-medication-safety-oncology-findings-2012-ismp
May 14, 2009 - Study
Establishing an international baseline for medication safety in oncology: findings from the 2012 ISMP International Medication Safety Self Assessment for Oncology.
Citation Text:
Greenall J, Shastay A, Vaida AJ, et al. Establishing an international baseline for medication safety in…
-
psnet.ahrq.gov/node/37077/psn-pdf
October 03, 2011 - Sensemaking, safety, and cooperative work in the
intensive care unit.
October 3, 2011
Albolino S, Cook RI, O’Connor M. Sensemaking, safety, and cooperative work in the intensive care unit.
Cog Tech Work. 2006;9(3):131-137. doi:10.1007/s10111-006-0057-5.
https://psnet.ahrq.gov/issue/sensemaking-safety-and-cooperati…
-
psnet.ahrq.gov/node/49515/psn-pdf
July 01, 2006 - that do serve peanuts offer a
"peanut-free buffer zone" to air travelers who request it.(7) The well-established … For food services departments with robust information systems, however, the same principals established
-
psnet.ahrq.gov/node/845361/psn-pdf
March 29, 2023 - A standardized marking procedure for ENT operations to
prevent wrong-site surgery: development, establishment
and subsequent evaluation among patients and medical
personnel.
March 29, 2023
Rohrmeier C, Abudan Al-Masry N, Keerl R, et al. A standardized marking procedure for ENT operations to
prevent wrong-site sur…
-
psnet.ahrq.gov/node/33763/psn-pdf
March 01, 2014 - followed by development of training and
certification programs (4,5) along with numerous guidelines established … Institutes of Health, Agency for Healthcare Research and Quality, and CDC) as well as the recently
established
-
psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
July 23, 2024 - care outcomes. 3 In addition, the Lean teams oversaw the implementation of the interventions they established … from senior leadership, a multidisciplinary team is convened, a standard definition of suicide risk is established … Spot checks help the innovators gauge whether the innovation is reaching the final target that was established
-
psnet.ahrq.gov/node/49428/psn-pdf
January 01, 2004 - To Resuscitate or Not?
January 1, 2004
Wu AW, Pronovost P. To Resuscitate or Not? PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/resuscitate-or-not
The Case
A critically ill end-stage AIDS patient was hospitalized for end-of-life care. Given the state of his disease,
his code status was Do Not Resuscitate/…
-
psnet.ahrq.gov/innovation/standardized-marking-procedure-ent-operations-prevent-wrong-site-surgery-development
February 01, 2013 - EMERGING INNOVATIONS
A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel.
Citation Text:
Rohrmeier C, Abudan Al-Masry N, Keerl R, et al. A standardized marking procedure for ENT…
-
psnet.ahrq.gov/node/50612/psn-pdf
October 30, 2019 - It is not reasonable for an overnight supervising
attending without an established trainee relationship … Psychological safety is established through inclusive leadership, a work environment focused on
continuous
-
psnet.ahrq.gov/node/38935/psn-pdf
March 01, 2017 - Leadership committed to safety.
December 23, 2016
Sentinel Event Alert. August 27, 2009;(43):1-3.
https://psnet.ahrq.gov/issue/leadership-committed-safety
Despite the past decade's focus on improving patient safety, most health care organizations are still striving
to achieve high reliability status—consistently p…
-
psnet.ahrq.gov/node/41313/psn-pdf
January 18, 2017 - Apology for errors: whose responsibility?
January 18, 2017
Leape L. Apology for errors: whose responsibility? Front Health Serv Manage. 2012;28(3):3-12.
https://psnet.ahrq.gov/issue/apology-errors-whose-responsibility
Although victims of adverse events have clearly expressed their preferences for full error disclos…
-
psnet.ahrq.gov/node/43447/psn-pdf
November 20, 2015 - Evaluating the effect of safety culture on error reporting:
a comparison of managerial and staff perspectives.
November 20, 2015
Richter J, McAlearney AS, Pennell ML. Evaluating the effect of safety culture on error reporting: a
comparison of managerial and staff perspectives. Am J Med Qual. 2015;30(6):550-8.
doi:…