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Total Results: 7,834 records

Showing results for "failures".

  1. Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission: a randomized clinical trial. | PSNet

    psnet.ahrq.gov/issue/effect-hospital-multifaceted-clinical-pharmacist-intervention-risk-readmission-randomized
    September 13, 2023 - Study Classic Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission: a randomized clinical trial. Citation Text: Ravn-Nielsen LV, Duckert M-L, Lund ML, et al. Effect of an In-Hospital Multifaceted Clinical Pharmacist I…

  2. Postoperative adverse events inconsistently improved by the World Health Organization surgical safety checklist: a systematic literature review of 25 studies. | PSNet

    psnet.ahrq.gov/issue/postoperative-adverse-events-inconsistently-improved-world-health-organization-surgical
    March 29, 2023 - Review Classic Postoperative adverse events inconsistently improved by the World Health Organization surgical safety checklist: a systematic literature review of 25 studies. Citation Text: de Jager E, McKenna C, Bartlett L, et al. Postoperative adverse events in…

  3. Association of off-label drug use and adverse drug events in an adult population. | PSNet

    psnet.ahrq.gov/issue/association-label-drug-use-and-adverse-drug-events-adult-population
    February 03, 2011 - Study Classic Association of off-label drug use and adverse drug events in an adult population. Citation Text: Eguale T, Buckeridge DL, Verma A, et al. Association of Off-label Drug Use and Adverse Drug Events in an Adult Population. JAMA Intern Med. 2016;176(1)…

  4. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. | PSNet

    psnet.ahrq.gov/issue/factors-associated-mental-health-outcomes-among-health-care-workers-exposed-coronavirus
    March 24, 2019 - Study Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. Citation Text: Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 20…

  5. A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel. | PSNet

    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…

  6. Implicit bias and patient care: mitigating bias, preventing harm. | PSNet

    psnet.ahrq.gov/innovation/implicit-bias-and-patient-care-mitigating-bias-preventing-harm
    September 22, 2021 - EMERGING INNOVATIONS Implicit bias and patient care: mitigating bias, preventing harm. Citation Text: Barber Doucet H, Wilson T, Vrablik L, et al. Implicit bias and patient care: mitigating bias, preventing harm. MedEdPORTAL. 2023;19:11343. doi:10.15766/mep_2374-8265.11343. Copy Citation …

  7. Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology. | PSNet

    psnet.ahrq.gov/issue/antecedent-treat-and-release-diagnoses-prior-sepsis-hospitalization-among-adult-emergency
    May 12, 2021 - Study Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology. Citation Text: Nassery N, Horberg MA, …

  8. Education outcomes from a duty-hour flexibility trial in internal medicine. | PSNet

    psnet.ahrq.gov/issue/education-outcomes-duty-hour-flexibility-trial-internal-medicine
    December 12, 2012 - Study Classic Education outcomes from a duty-hour flexibility trial in internal medicine. Citation Text: Desai SV, Asch DA, Bellini LM, et al. Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine. New Engl J Med. 2018;378(16):1494-1508. doi:1…

  9. "Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety. | PSNet

    psnet.ahrq.gov/issue/good-care-slow-enough-be-able-pay-attention-primary-care-time-scarcity-and-patient-safety
    August 04, 2015 - Study "Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety. Citation Text: Satterwhite S, Nguyen M-LT, Honcharov V, et al. "Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety. J Gen Intern …

  10. Patient-related factors associated with an increased risk of being a reported case of preventable harm in first-line health care: a case-control study | PSNet

    psnet.ahrq.gov/issue/patient-related-factors-associated-increased-risk-being-reported-case-preventable-harm-first
    October 09, 2019 - Study Patient-related factors associated with an increased risk of being a reported case of preventable harm in first-line health care: a case-control study Citation Text: Fernholm R, Holzmann MJ, Wachtler C, et al. Patient-related factors associated with an increased risk of being a rep…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74121/psn-pdf
    November 30, 2021 - alarm-related sentinel events including alarm fatigue (most common), as well as equipment malfunctions/failures

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49681/psn-pdf
    April 01, 2013 - As occurred in this case, multiple failures across the PN-use process are usually identified in retrospect

  13. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. | PSNet

    psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
    September 25, 2019 - WebM&M Cases Delay in Malignancy Diagnosis Reflects Systemic Failures

  14. Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle | PSNet

    psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
    July 23, 2024 - exploration; 2) a surgical debrief; 3) a visual counter; 4) imaging; and if needed, 5) the reporting of failures

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866826/psn-pdf
    September 25, 2024 - Despite the multiple safety features on anesthesia machines to prevent cross- connection, rare safety failures

  16. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care | PSNet

    psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
    June 01, 2003 - "holes" in nurse staffing are allowed to remain unfilled at times like these, my guess is that such failures

  17. Coming Up Short: Maintaining Safety in the Face of Drug Shortages | PSNet

    psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
    November 01, 2012 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages Citation Text: Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33751/psn-pdf
    January 01, 2014 - Strengthening the Business Case for Patient Safety May 1, 2013 Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety Perspective After more than a decade in the national spotlight, the problem of pati…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49523/psn-pdf
    November 01, 2006 - Urinary Retention Dilemma November 1, 2006 Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma The Case Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy (BPH) and urinary hesitancy returned to th…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49670/psn-pdf
    November 01, 2012 - Missed Pneumonia November 1, 2012 Rohde JM, Flanders S. Missed Pneumonia. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/missed-pneumonia The Case A 32-year-old man presented to the emergency department (ED) with 3 days of fever and right pleuritic chest pain. Review of systems was negative for cough or dy…
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