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psnet.ahrq.gov/issue/preventing-patient-harms-through-systems-care
February 27, 2014 - Recognizing this fact, this commentary calls for a systems engineering approach to identifying and preventing
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psnet.ahrq.gov/node/33637/psn-pdf
August 01, 2006 - He took an interest in the fact that I had some training in
health policy work. … And although I've been outspoken
about saying "it's not bad people; it's bad systems," the fact is that … that it's mostly about systems,
but in fact there are some "bad" people. … LL: On the apology front, I'm very concerned that people put too much emphasis on the fact that this … I've
been struck by the fact that openness, transparency, and full disclosure and apology when indicated
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psnet.ahrq.gov/node/34055/psn-pdf
March 07, 2005 - As a result, Medicare served as an
important facilitator of safety efforts due to the fact that hospitals
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psnet.ahrq.gov/node/39322/psn-pdf
February 24, 2010 - complications-and-death-start-new-academic-year-there-july-phenomenon
Trauma patients admitted in the early weeks of the academic year were in fact
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psnet.ahrq.gov/node/39192/psn-pdf
February 02, 2011 - This risk was borne out in the
study, as patients who received the contraindicated medications did in fact
-
psnet.ahrq.gov/node/35565/psn-pdf
June 16, 2011 - discussing errors seems to be a
greater challenge in medicine than in aviation, which may derive from the fact
-
psnet.ahrq.gov/node/45537/psn-pdf
July 27, 2018 - Most patient safety research and initiatives have focused on the hospital environment, despite the fact
-
psnet.ahrq.gov/node/44948/psn-pdf
February 14, 2017 - In the preface, the authors say the title reflects the fact that
most current safety initiatives are
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psnet.ahrq.gov/issue/our-patients-and-their-visitors-help-prevent-infections
May 08, 2013 - Fact Sheet/FAQs
For Our Patients and Their Visitors: Help Prevent Infections.
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psnet.ahrq.gov/node/37701/psn-pdf
February 22, 2011 - Incident reporting systems are ubiquitous, but are limited by low clinician reporting rates and the fact
-
psnet.ahrq.gov/node/37480/psn-pdf
January 23, 2008 - The authors conclude that physicians
are in fact engaged in discussing errors but that current systems
-
psnet.ahrq.gov/node/38865/psn-pdf
April 04, 2011 - This need was felt most strongly by parents with limited English skills, and in fact, prior research
-
psnet.ahrq.gov/node/852699/psn-pdf
August 30, 2023 - ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
https://www.hhs.gov/
https://www.hhs.gov/about/news/2023/05/09/fact-sheet-end-of-the-covid … //psnet.ahrq.gov/primer/telehealth-and-patient-safety
https://www.hhs.gov/about/news/2023/05/10/hhs-fact-sheet-telehealth-flexibilities-resources-covid … https://www.medicaid.gov/medicaid/home-community-based-services/index.html
https://www.cms.gov/newsroom/fact-sheets … cms-waivers-flexibilities-and-transition-forward-covid-19-public-health-emergency
https://www.cms.gov/newsroom/fact-sheets
-
psnet.ahrq.gov/issue/60-year-old-man-delayed-care-renal-mass
January 31, 2024 - The fact that JAMA chose a clinical scenario focusing on systems failures mirrors past efforts in the
-
psnet.ahrq.gov/node/866055/psn-pdf
May 29, 2024 - https://www.cms.gov/newsroom/fact-sheets/eliminating-
serious-preventable-and-costly-medical-errors-never-events … insights/what-is-a-bundle
https://www.ihi.org/insights/what-is-a-bundle
https://www.cms.gov/newsroom/fact-sheets … eliminating-serious-preventable-and-costly-medical-errors-never-events
https://www.cms.gov/newsroom/fact-sheets … https://www.who.int/news-room/fact-sheets/detail/patient-safety
7. … outpatient-surgery/the-magazine/article/the-high-cost-of-retained-surgical-items
https://www.who.int/news-room/fact-sheets
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.341_slideshow.ppt
March 01, 2015 - PowerPoint Presentation
Spotlight
Two Wrongs Don't Make a Right (Kidney)
This presentation is based on the March 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John G. DeVine, MD, Professor of Orthopaedic Surgery, Medical College of Georgia
Ed…
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psnet.ahrq.gov/web-mm/polypharmacy
March 01, 2007 - The patient accepted the risperidone without disclosing this fact to his caregiver or case manager. … In fact, the community pharmacy had a fully accurate list only 25% of the time (versus only 8% with primary … An additional issue is the fact that some expensive drugs (like the depot injections of risperidone)
-
psnet.ahrq.gov/node/37706/psn-pdf
December 23, 2016 - the importance of dosing errors (eg, weight-related and
calculation-related errors), as well as the fact
-
psnet.ahrq.gov/issue/cps-annual-reports
March 25, 2009 - Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact
-
psnet.ahrq.gov/node/41119/psn-pdf
July 03, 2016 - Despite this sobering fact, a recent review
found virtually no proven mechanisms for detecting or preventing