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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36900/psn-pdf
    April 18, 2011 - Consequences of running more operating theatres than anaesthetists to staff them: a stochastic simulation study. April 18, 2011 Paoletti X, Marty J. Consequences of running more operating theatres than anaesthetists to staff them: a stochastic simulation study. Br J Anaesth. 2007;98(4):462-9. https://psnet.ahrq.go…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34989/psn-pdf
    February 24, 2011 - Laboratory safety monitoring of chronic medications in ambulatory care settings. February 24, 2011 Hurley JS, Roberts M, Solberg LI, et al. Brief report: Laboratory safety monitoring of chronic medications in ambulatory care settings. J Gen Intern Med. 2005;20(4). doi:10.1111/j.1525-1497.2005.40182.x. https://psne…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865977/psn-pdf
    May 29, 2024 - Complication rates of central venous catheters: a systematic review and meta-analysis. May 29, 2024 Teja B, Bosch NA, Diep C, et al. Complication rates of central venous catheters: a systematic review and meta-analysis. JAMA Intern Med. 2024;184(5):474-482. doi:10.1001/jamainternmed.2023.8232. https://psnet.ahrq.g…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47020/psn-pdf
    January 16, 2019 - Unintended harm associated with the Hospital Readmissions Reduction Program. January 16, 2019 Fonarow GC. Unintended Harm Associated With the Hospital Readmissions Reduction Program. JAMA. 2018;320(24):2539-2541. doi:10.1001/jama.2018.19325. https://psnet.ahrq.gov/issue/unintended-harm-associated-hospital-readmiss…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47832/psn-pdf
    February 27, 2019 - Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture. February 27, 2019 ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24. https://psnet.ahrq.gov/issue/another-round-blame-game-paralyzing-criminal-indictment-recklessly- overrides-just-cultu…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60359/psn-pdf
    May 20, 2020 - Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. May 20, 2020 ISMP Medication Safety Alert! Acute care edition. May 7, 2020;25(9). https://psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone- overdose Lack of familiarity with sm…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46125/psn-pdf
    August 03, 2017 - Exploring the experience of nurse practitioners who have committed medical errors: a phenomenological approach. August 3, 2017 Delacroix R. Exploring the experience of nurse practitioners who have committed medical errors: A phenomenological approach. J Am Assoc Nurse Pract. 2017;29(7):403-409. doi:10.1002/2327-692…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61058/psn-pdf
    October 28, 2020 - Interventions and measurements of highly reliable/resilient organization implementations: a literature review. October 28, 2020 Cantu J, Tolk J, Fritts S, et al. Interventions and measurements of highly reliable/resilient organization implementations: a literature review. Appl Ergon. 2020;90:103241. doi:10.1016/j.…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839315/psn-pdf
    January 01, 2024 - Six major steps to make investigations of suicide valuable for learning and prevention. November 2, 2022 Fröding E, Vincent C, Andersson-Gäre B, et al. Six major steps to make investigations of suicide valuable for learning and prevention. Arch Suicide Res. 2024;28(1):1-19. doi:10.1080/13811118.2022.2133652. https…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50848/psn-pdf
    January 29, 2020 - Deficiencies in Care Coordination and Facility Response to a Patient Suicide at the Minneapolis VA Health Care System, Minnesota. January 29, 2020 Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 7, 2020. Report No. 19-00468-67. https://psnet.ahrq.gov/issue/deficiencies-care-co…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43715/psn-pdf
    November 26, 2014 - An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study. November 26, 2014 Moyer VA, Papile L-A, Eichenwald E, et al. An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study. BMJ Qual Saf. 2014;23(12):e3. https://psnet.ahrq.gov/issue/inter…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36718/psn-pdf
    July 26, 2011 - Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians. July 26, 2011 Davidenko JM, Snyder LS. Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians. J Electrocardiol. 2007;40(5):450-6. https://psnet.ahrq.gov/issue/causes-errors-electrocard…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41561/psn-pdf
    August 01, 2012 - Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems. August 1, 2012 Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2012. Report No. OEI-06-09-00092. https://psnet.ahrq.gov/issue/few-adverse-events-hospitals-were-reporte…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836775/psn-pdf
    March 23, 2022 - Embracing multiple aims in healthcare improvement and innovation. March 23, 2022 Amalberti R, Staines A, Vincent CA. Embracing multiple aims in healthcare improvement and innovation. Int J Qual Health Care. 2022;34(1):mzac006. doi:10.1093/intqhc/mzac006. https://psnet.ahrq.gov/issue/embracing-multiple-aims-healthc…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43992/psn-pdf
    April 25, 2016 - Collaborating—or "selling" patients? A conceptual framework for emergency department-to-inpatient handoff negotiations. April 25, 2016 Hilligoss B, Mansfield JA, Patterson ES, et al. Collaborating-or "Selling" Patients? A Conceptual Framework for Emergency Department-to-Inpatient Handoff Negotiations. Jt Comm J Qu…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44922/psn-pdf
    March 01, 2017 - Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study. March 1, 2017 Korkiakangas T. Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study. BMJ Qual Saf. 2017;26(3):177-188. doi:10.1136/bmjqs-2015-004887. https://psnet.ahrq.gov/issue/mobilising-team-who-sur…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43870/psn-pdf
    January 28, 2015 - Peer review of medical practices: missed opportunities to learn. January 28, 2015 Kadar N. Peer review of medical practices: missed opportunities to learn. Am J Obstet Gynecol. 2014;211(6):596-601. doi:10.1016/j.ajog.2014.08.018. https://psnet.ahrq.gov/issue/peer-review-medical-practices-missed-opportunities-learn…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47638/psn-pdf
    February 06, 2019 - Decreasing surgical site infections by developing a high reliability culture. February 6, 2019 Pettis AM. Decreasing Surgical Site Infections by Developing a High Reliability Culture. AORN J. 2018;108(6):644-650. doi:10.1002/aorn.12416. https://psnet.ahrq.gov/issue/decreasing-surgical-site-infections-developing-hi…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60676/psn-pdf
    July 15, 2020 - Northeastern University Hospital Surge Capacity Planning Model: Bed, Ventilator, and PPE 1-30 Day Demand. July 15, 2020 Rockville, MD; Agency for Healthcare Research and Quality: 2020. https://psnet.ahrq.gov/issue/northeastern-university-hospital-surge-capacity-planning-model-bed-ventilator- and-ppe-1-30 The COVI…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866728/psn-pdf
    September 18, 2024 - ROI for a fall prevention intervention: invest a little, save a lot. September 18, 2024 Cooper AS. ROI for a fall prevention intervention: invest a little, save a lot. Nurs Adm Q. 2024;48(3):248- 252. doi:10.1097/naq.0000000000000647. https://psnet.ahrq.gov/issue/roi-fall-prevention-intervention-invest-little-save…
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