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psnet.ahrq.gov/node/838017/psn-pdf
September 07, 2022 - addressing-adultification-black-pediatric-patients-emergency-department-
framework-decrease
Racial biases have been uncovered in pediatric emergency care; for example
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psnet.ahrq.gov/node/60005/psn-pdf
March 04, 2020 - This report highlights
one project as an example of how to involve patients as partners in diagnostic
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psnet.ahrq.gov/node/73107/psn-pdf
April 07, 2021 - Building on an example from emergency medicine, the authors highlight the importance of implementation
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psnet.ahrq.gov/node/47864/psn-pdf
April 08, 2019 - individual-clinician-performance-issues
https://psnet.ahrq.gov/issue/intentionally-harmful-violations-and-patient-safety-example-harold-shipman
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psnet.ahrq.gov/node/36839/psn-pdf
May 11, 2014 - discuss targeting and prioritizing improvement efforts in
medication safety programs and share an example
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psnet.ahrq.gov/node/39412/psn-pdf
January 03, 2017 - health-care-serial-murder-patient-safety-orphan
https://psnet.ahrq.gov/issue/intentionally-harmful-violations-and-patient-safety-example-harold-shipman
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psnet.ahrq.gov/node/42267/psn-pdf
September 12, 2016 - clinical-dilemmas-and-review-strategies-manage-drug-shortages
https://psnet.ahrq.gov/issue/impact-drug-shortages-children-cancer-example-mechlorethamine
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psnet.ahrq.gov/node/33596/psn-pdf
June 01, 2025 - For example, Gaba described most anesthetic accidents as evolving from
small errors and system failures … For example, resilient capacities
may be required to successfully manage postoperative deterioration … For example, a woman with no known comorbid conditions undergoes an
abdominal hysterectomy and develops … complication also increase the likelihood of failure-to-rescue after
serious complications.6,7,8 For example
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psnet.ahrq.gov/node/50930/psn-pdf
February 21, 2020 - For example, community pharmacists have historically
provided patients counseling services and communication … For example, one institution developed a pharmacist-led
prior authorization drug request program with … For example, automated dispensing
cabinets in hospital patient care areas support efficient nursing … For example, the use of some technologies, such as robotics for
medication dispensing, can reduce errors
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psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
August 31, 2020 - For example, one study found that during the diagnosis process in the emergency department (ED), 23% … For example, in the development of advance care planning documentation, one study concluded that interventions … For example, interdisciplinary bedside rounding approaches bring together clinicians with the goal … For example, a survey of over 500 OB/GYNs indicated an opportunity to improve available tools for communicating
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psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
June 29, 2020 - For example, community pharmacists have historically provided patients counseling services and communication … For example, one institution developed a pharmacist-led prior authorization drug request program with … For example, automated dispensing cabinets in hospital patient care areas support efficient nursing response … For example, the use of some technologies, such as robotics for medication dispensing, can reduce errors
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psnet.ahrq.gov/node/854251/psn-pdf
October 04, 2023 - The author asserts more research
and education is needed outside dermatology, for example, when assessments
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psnet.ahrq.gov/node/858164/psn-pdf
December 13, 2023 - national-surgical-quality-improvement-program
https://psnet.ahrq.gov/issue/promoting-patient-safety-through-prospective-risk-identification-example-peri-operative-care
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psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
March 01, 2011 - often lack important elements, and that poor quality handovers can cause adverse consequences.( 1 ) For example … For example, in disciplines like emergency medicine and OBGYN that have structured shifts—often when … For example, a shift change where the sender is returning is going to be very different from a service … Another example would be transferring the patient to a different specialty service. … For example, while everyone wants the well-rested intern to put in an arterial line, the results were
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - For example, the rate of pressure ulcers in nursing homes has been shown to range between 2.2% to 23.9% … For example, in the Institute of Medicine report on Preventing Medication Errors, approximately 800,000 … For example, nursing homes can monitor their organization's fall rates, pressure ulcer rates, and infection … For example, technology systems can be designed to identify high-risk residents (e.g., pressure ulcer … For example, nursing homes can conduct daily safety briefings where frontline caregivers are provided
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psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - For example, at Beth Israel Deaconess Medical Center, physicians and nurses have purchased more than … For example, a mobile device could carry harmful bacteria if not disinfected between patient encounters … For example, consumer devices may include convenience functions to store and replay passwords; if lost … enable work related and consumer functions to be isolated from each other, minimizing the risk for example … For example, in Defense Department settings, all cameras on employer-provided mobile devices are disabled
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psnet.ahrq.gov/node/33696/psn-pdf
June 01, 2010 - If you look at diagnostic error for example,
it's highest in the disciplines with the most uncertainty … For example, if a nurse or a colleague comes to you and
says, "Oh, so and so is here. … Most of us were
trained on prototypes, for example, this is what chest pain looks like. … If you take, for example, a borderline patient or a patient who's being
obstructive, they create a negative … Diagnostic acumen, for
example, is the one thing that physicians hold very dear.
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psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
September 15, 2024 - For example, when reducing and repairing a fracture using plates or screws, the final construct is not … For example, if plain radiographs have not been helpful, the team may decide to get computed tomography … unretrieved device or device fragment and (2) keeps a record of cases to identify trends and patterns (for example … For example, data from one of the best state reporting systems provides information about the relative
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psnet.ahrq.gov/node/867339/psn-pdf
December 11, 2024 - Participants also state there can be an overreliance on the RRT; for example, if ward
nurses cannot
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psnet.ahrq.gov/node/866517/psn-pdf
August 14, 2024 - For example, men presenting with "classic" symptoms of heart attack are more frequently targeted
for