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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50731/psn-pdf
    December 11, 2019 - Awareness of diagnosis and follow up care after discharge from the emergency department December 11, 2019 Leamy K, Thompson J, Mitra B. Awareness of diagnosis and follow up care after discharge from the Emergency Department. Australas Emerg Care. 2019;22(4):221-226. doi:10.1016/j.auec.2019.08.004. https://psnet.ah…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37981/psn-pdf
    June 16, 2011 - Nurses' perceptions of error communication and reporting in the intensive care unit. June 16, 2011 Elder NC, Brungs SM, Nagy M, et al. Nurses' Perceptions of Error Communication and Reporting in the Intensive Care Unit. J Patient Saf. 2008;4(3). doi:10.1097/pts.0b013e3181839b48. https://psnet.ahrq.gov/issue/nurses…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43139/psn-pdf
    April 23, 2014 - Patient safety in obstetrics and obstetric anesthesia. April 23, 2014 Kung A, Pratt SD. Patient safety in obstetrics and obstetric anesthesia. Int Anesthesiol Clin. 2014;52(2):86- 110. doi:10.1097/AIA.0000000000000017. https://psnet.ahrq.gov/issue/patient-safety-obstetrics-and-obstetric-anesthesia Labor and delive…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45713/psn-pdf
    November 22, 2017 - Assigning responsibility to close the loop on radiology test results. November 22, 2017 Kwan JL, Singh H. Assigning responsibility to close the loop on radiology test results. Diagnosis (Berl). 2017;4(3):173-177. doi:10.1515/dx-2017-0019. https://psnet.ahrq.gov/issue/assigning-responsibility-close-loop-radiology-t…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860733/psn-pdf
    January 17, 2024 - Staff warned about the lack of psychiatric care at a VA clinic. They couldn’t prevent tragedy. January 17, 2024 McGrory K, Bedi N. ProPublica, January 6, 2024. https://psnet.ahrq.gov/issue/staff-warned-about-lack-psychiatric-care-va-clinic-they-couldnt-prevent-tragedy Stories of mental health system failure provid…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60807/psn-pdf
    August 12, 2020 - Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center. August 12, 2020 Office of the Inspector General. Washington, DC: Department of Veterans Affairs; July 28, 2020. Report Number 19-07507-214. https://psnet.ahrq.gov/issue/inadequate-emergency-department-care-and-phy…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39256/psn-pdf
    November 14, 2011 - Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009. November 14, 2011 Oakbrook Terrace, IL: The Joint Commission; January 2010. https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and- safety-2009 America's hospitals continu…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43881/psn-pdf
    February 11, 2015 - Cognitive Systems Engineering in Health Care. February 11, 2015 Bisantz AM, Burns CM, Fairbanks RJ, eds. Boca Raton, FL: CRC Press; 2014. ISBN: 9781466587960. https://psnet.ahrq.gov/issue/cognitive-systems-engineering-health-care This publication provides information about the role of cognition in medical error. Th…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46089/psn-pdf
    July 26, 2017 - A new patient safety smartphone application for prevention of "forgotten" ureteral stents: results from a clinical pilot study in 194 patients. July 26, 2017 Molina WR, Pessoa R, da Silva RD, et al. A new patient safety smartphone application for prevention of "forgotten" ureteral stents: results from a clinical p…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867020/psn-pdf
    October 23, 2024 - What can we learn from coroners’ reports on preventable deaths? October 23, 2024 Jeraj S. What can we learn from coroners’ reports on preventable deaths? BMJ. 2024;386:q1943. https://psnet.ahrq.gov/issue/what-can-we-learn-coroners-reports-preventable-deaths Analysis of system failure is only the beginning of the i…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43971/psn-pdf
    April 25, 2016 - Why empathy may be the best risk management strategy. April 25, 2016 Hertz BT. Why empathy may be the best risk management strategy. Medical economics. 2015;92(3):40-4. https://psnet.ahrq.gov/issue/why-empathy-may-be-best-risk-management-strategy Communication and response strategies have been shown to improve how …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60564/psn-pdf
    June 03, 2020 - Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts? June 3, 2020 ISMP Medication Safety Alert! Acute Care Edition. May 22, 2020;25(10). https://psnet.ahrq.gov/issue/subtherapeutic-heparin-infusions-your-organization-risk-bypassing-soft-low- dose-alerts Smart infusion …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47355/psn-pdf
    September 05, 2018 - Preventing medication errors in the information age. September 5, 2018 Godshall M, Riehl M. Preventing medication errors in the information age. Nursing (Brux). 2018;48(9):56- 58. doi:10.1097/01.NURSE.0000544230.51598.38. https://psnet.ahrq.gov/issue/preventing-medication-errors-information-age Failure to consider…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46216/psn-pdf
    July 12, 2017 - Physician satisfaction with transition from CPOE to paper-based prescription. July 12, 2017 Griffon N, Schuers M, Joulakian M, et al. Physician satisfaction with transition from CPOE to paper-based prescription. Int J Med Inform. 2017;103:42-48. doi:10.1016/j.ijmedinf.2017.04.007. https://psnet.ahrq.gov/issue/phys…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43931/psn-pdf
    March 04, 2015 - Design of endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes may impede effective cleaning. March 4, 2015 FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 23, 2015. https://psnet.ahrq.gov/issue/design-endoscopic-retrograde-cholangiopancreatography-ercp- duode…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43092/psn-pdf
    April 02, 2014 - Do you hear what I hear? Communication practices about medications between physicians and clients with chronic illness in Canada. April 2, 2014 Sears K, Bishop A, MacKinnon NJ. J Particip Med. 2014;6:e2. https://psnet.ahrq.gov/issue/do-you-hear-what-i-hear-communication-practices-about-medications- between-physic…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44738/psn-pdf
    May 21, 2016 - The Habits of an Improver. Thinking About Learning for Improvement in Health Care. May 21, 2016 Lucas B, Nacer H. London, UK: Health Foundation; October 2015. ISBN: 9781906461676. https://psnet.ahrq.gov/issue/habits-improver-thinking-about-learning-improvement-health-care Committed leadership is essential to enhan…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44050/psn-pdf
    September 27, 2017 - Unfinished nursing care, missed care, and implicitly rationed care: state of the science review. September 27, 2017 Jones TL, Hamilton P, Murry N. Unfinished nursing care, missed care, and implicitly rationed care: State of the science review. Int J Nurs Stud. 2015;52(6):1121-1137. doi:10.1016/j.ijnurstu.2015.02.01…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39454/psn-pdf
    October 04, 2017 - The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. October 4, 2017 Reason J. Farnham Surrey, UK: Ashgate; 2008. ISBN: 9780754674023. https://psnet.ahrq.gov/issue/human-contribution-unsafe-acts-accidents-and-heroic-recoveries The British psychologist James Reason’s insights into the nature of hum…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865926/psn-pdf
    May 22, 2024 - Critical care nurses' role in rapid response teams: a qualitative systematic review. May 22, 2024 Holtsmark C, Larsen MH, Steindal SA, et al. Critical care nurses' role in rapid response teams: a qualitative systematic review. J Clin Nurs. 2024;33(10):3831-3843. doi:10.1111/jocn.17196. https://psnet.ahrq.gov/issue…
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