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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44790/psn-pdf
    March 15, 2016 - The role of emotion in patient safety: are we brave enough to scratch beneath the surface? March 15, 2016 Heyhoe J, Birks Y, Harrison R, et al. The role of emotion in patient safety: Are we brave enough to scratch beneath the surface? J R Soc Med. 2016;109(2):52-8. doi:10.1177/0141076815620614. https://psnet.ahrq.…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60292/psn-pdf
    May 06, 2020 - Overcoming COVID-19: what can human factors and ergonomics offer? May 6, 2020 Gurses AP, Tschudy MM, McGrath-Morrow S, et al. Overcoming COVID-19: what can human factors and ergonomics offer? J Patient Saf Risk Manag. 2020;25(2):49-54. doi:10.1177/2516043520917764. https://psnet.ahrq.gov/issue/overcoming-covid-19-…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846764/psn-pdf
    March 29, 2023 - Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane. March 29, 2023 Donovan-Smith O. Spokesman Review. March 15, 2023. https://psnet.ahrq.gov/issue/senators-threaten-consequences-after-va-confirms-4-deaths-tied-computer- system-tested-spokane Implementations of elec…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837037/psn-pdf
    May 04, 2022 - Humanizing harm: using a restorative approach to heal and learn from adverse events. May 4, 2022 Wailling J, Kooijman A, Hughes J, et al. Humanizing harm: Using a restorative approach to heal and learn from adverse events. Health Expect. 2022;25(4):1192-1199. doi:10.1111/hex.13478. https://psnet.ahrq.gov/issue/hum…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60233/psn-pdf
    April 15, 2020 - Identifying safety hazards associated with intravenous vancomycin through the analysis of patient safety event reports. April 15, 2020 Krukas A, Franklin ES, Bonk C, et al. Identifying safety hazards associated with intravenous vancomycin through the analysis of patient safety event reports. Patient Safety. 2020;2…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60559/psn-pdf
    June 03, 2020 - Omissions of care in nursing home settings: a narrative review. June 3, 2020 Ogletree AM, Mangrum R, Harris Y, et al. Omissions of care in nursing home settings: a narrative review. J Am Med Dir Assoc. 2020;21(5):604-614.e6. doi:10.1016/j.jamda.2020.02.016. https://psnet.ahrq.gov/issue/omissions-care-nursing-home-…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48073/psn-pdf
    June 19, 2019 - Special Section on Human Factors and Ergonomics in the Operating Room: Contributions That Advance Surgical Practice. June 19, 2019 Hallbeck MS, Paquet V, eds. Appl Ergon. 2019;78:248-308. https://psnet.ahrq.gov/issue/special-section-human-factors-and-ergonomics-operating-room-contributions- advance-surgical Surg…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60003/psn-pdf
    January 01, 2021 - Systemic causes of in-hospital intravenous medication errors: a systematic review. March 4, 2020 Kuitunen S, Niittynen I, Airaksinen M, et al. Systemic causes of in-hospital intravenous medication errors: a systematic review. J Patient Saf. 2021;17(8):e1660-e1668. doi:10.1097/pts.0000000000000632. https://psnet.ah…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36680/psn-pdf
    July 10, 2008 - Identifying diagnostic errors in primary care using an electronic screening algorithm. July 10, 2008 Singh H, Thomas EJ, Khan MM, et al. Identifying diagnostic errors in primary care using an electronic screening algorithm. Arch Intern Med. 2007;167(3):302-308. https://psnet.ahrq.gov/issue/identifying-diagnostic-e…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47099/psn-pdf
    May 16, 2018 - Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up. May 16, 2018 Washington, DC: United States Government Accountability Office; April 2018. Publication GAO-18-378. https://psnet.ahrq.gov/issue/defense-health-agency-should-improve-tracking-serious-a…

  11. Group Health Cooperative | Digital Healthcare Research

    digital.ahrq.gov/organization/group-health-cooperative
    January 01, 2023 - Group Health Cooperative Understanding and Honoring Patients with Multiple Chronic Conditions Description This project determined care priorities for patients with multiple chronic conditions based on patient needs, preferences, and capabilities and developed a set of recommen…

  12. Kidney-Disease-Medicine Surveillance (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/kidney-disease-medicine_surveillance.pdf
    October 01, 2012 - CER # 37: Chronic Kidney Disease Stages 1–3: Screening, Monitoring, and Treatment Original release date: January 2012 Surveillance Report: October 2012 Key Findings: - The conclusions for KQ2 (harms of screening) and KQ4 (harms of monitoring), KQ6 (harms of treatment) are still considered valid - T…

  13. Right Patient, Wrong Sample | PSNet

    psnet.ahrq.gov/web-mm/right-patient-wrong-sample
    June 01, 2004 - Right Patient, Wrong Sample Citation Text: Astion ML. Right Patient, Wrong Sample. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846170/psn-pdf
    March 15, 2023 - Duplicate Therapies in Retail Pharmacy March 15, 2023 Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy The Cases Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection f…

  15. Elopement | PSNet

    psnet.ahrq.gov/web-mm/elopement
    July 14, 2010 - SPOTLIGHT CASE Elopement Citation Text: Gerardi D. Elopement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…

  16. Novel Drug Misuse | PSNet

    psnet.ahrq.gov/web-mm/novel-drug-misuse
    September 30, 2010 - SPOTLIGHT CASE Novel Drug Misuse Citation Text: Angus DC, Milbrandt EB. Novel Drug Misuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…

  17. Hospital Inpatient Statistics, 1996

    hcup-us.ahrq.gov/reports/natstats/his96/table1b.htm
    January 01, 1996 - Hospital Inpatient Statistics, 1996 Table 1 (continued). Statistics for 1996 HCUP Nationwide Inpatient Sample, by multi-level CCS diagnosis (principal diagnosis only) ___________________________________________________________________________________________________________________________________________…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49454/psn-pdf
    July 01, 2004 - Novel Drug Misuse July 1, 2004 Angus DC, Milbrandt EB. Novel Drug Misuse. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/novel-drug-misuse Case Objectives Define the inclusion and exclusion criteria for patients in PROWESS. Understand why the FDA included APACHE score as an indication criterion for drotrec…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73336/psn-pdf
    May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers May 26, 2021 Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers The Case  …

  20. Head of Bed Elevation or Semirecumbent Positioning Literature Review | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/mvp/modules/technical/head-bed-elevation-lit-review.html
    January 01, 2017 - Head of Bed Elevation or Semirecumbent Positioning Literature Review AHRQ Safety Program for Mechanically Ventilated Patients Summary The elevation of the head of bed (HOB) to a semirecumbent position (at least 30 degrees) is associated with a decreased incidence of aspiration and ventilator-ass…
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