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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45098/psn-pdf
    May 04, 2016 - Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report. May 4, 2016 The Clinical Center Working Group Report to the Advisory Committee to the Director, National Institutes of Health. Bethesda, MD; National Institutes of Health; April 2016. https://psnet.ahrq.gov/issue/reducing…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865479/psn-pdf
    April 03, 2024 - Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases and complaints in Canada. April 3, 2024 Kwan JL, Calder LA, Bowman CL, et al. Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases and complaints …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841156/psn-pdf
    October 10, 2010 - “Those found responsible have been sacked”: some observations on the usefulness of error. October 10, 2010 Cook RI, Nemeth CP. “Those found responsible have been sacked”: some observations on the usefulness of error. Cogn Tech Work. 2010;12(2):87-93. doi:10.1007/s10111-010-0149-0. https://psnet.ahrq.gov/issue/thos…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861277/psn-pdf
    January 24, 2024 - Clinical deterioration as a nurse sensitive indicator in the out-of-hospital context: a scoping review. January 24, 2024 Mccullough K, Baker M, Bloxsome D, et al. Clinical deterioration as a nurse sensitive indicator in the out?of ?hospital context: a scoping review. J Clin Nurs. 2024;33(3):874-889. doi:10.1111/joc…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43383/psn-pdf
    August 13, 2014 - Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. August 13, 2014 Moffatt-Bruce SD, Cook CH, Steinberg SM, et al. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. J Surg Res. 2014;190(2):429-36. doi:10.1016/j.jss.2014…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74265/psn-pdf
    January 19, 2022 - Psychometric properties of the perinatal missed care survey and missed care during labor and birth. January 19, 2022 Lyndon A, Simpson KR, Spetz J, et al. Psychometric properties of the perinatal missed care survey and missed care during labor and birth. Appl Nurs Res. 2022;63:151516. doi:10.1016/j.apnr.2021.151516…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42626/psn-pdf
    October 02, 2013 - Improving patient safety in the ICU by prospective identification of missing safety barriers using the Bow-Tie prospective risk analysis model. October 2, 2013 Kerckhoffs MC, van der Sluijs AF, Binnekade JM, et al. Improving Patient Safety in the ICU by Prospective Identification of Missing Safety Barriers Using t…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43780/psn-pdf
    September 09, 2015 - Rapid response systems and collective (in)competence: an exploratory analysis of intraprofessional and interprofessional activation factors. September 9, 2015 Kitto S, Marshall SD, McMillan SE, et al. Rapid response systems and collective (in)competence: An exploratory analysis of intraprofessional and interprofes…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46184/psn-pdf
    January 01, 2018 - A prospective risk assessment of informal carers' medication administration errors within the domiciliary setting. December 19, 2017 Parand A, Faiella G, Franklin BD, et al. A prospective risk assessment of informal carers' medication administration errors within the domiciliary setting. Ergonomics. 2018;61(1):104…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838911/psn-pdf
    October 26, 2022 - Medication adverse events in the ambulatory setting: a mixed-methods analysis. October 26, 2022 Wong J, Lee S-Y, Sarkar U, et al. Medication adverse events in the ambulatory setting: a mixed-methods analysis. Am J Health Syst Pharm. 2022;79(24):2230-2243. doi:10.1093/ajhp/zxac253. https://psnet.ahrq.gov/issue/medi…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46428/psn-pdf
    November 01, 2017 - Translating staff experience into organisational improvement: the HEADS-UP stepped wedge, cluster controlled, non-randomised trial. November 1, 2017 Pannick S, Athanasiou T, Long SJ, et al. Translating staff experience into organisational improvement: the HEADS-UP stepped wedge, cluster controlled, non-randomised …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39120/psn-pdf
    March 04, 2011 - Time-dependent drug–drug interaction alerts in care provider order entry: software may inhibit medication error reductions. March 4, 2011 van der Sijs H, Lammers L, van den Tweel A, et al. Time-dependent drug-drug interaction alerts in care provider order entry: software may inhibit medication error reductions. J …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47693/psn-pdf
    January 23, 2019 - Solving alarm fatigue with smartphone technology. January 23, 2019 Short K, Chung YJ. Solving alarm fatigue with smartphone technology. Nursing (Brux). 2019;49(1):52-57. doi:10.1097/01.NURSE.0000549728.37810.d9. https://psnet.ahrq.gov/issue/solving-alarm-fatigue-smartphone-technology Alarm fatigue contributes to d…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45515/psn-pdf
    November 16, 2016 - The alarming reality of medication error: a patient case and review of Pennsylvania and national data. November 16, 2016 da Silva BA, Krishnamurthy M. The alarming reality of medication error: a patient case and review of Pennsylvania and National data. J Community Hosp Intern Med Perspect. 2016;6(4):31758. doi:10…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36837/psn-pdf
    December 03, 2018 - Hospitals as cultures of entrapment: a re-analysis of the Bristol Royal Infirmary. December 3, 2018 Weick KE, Sutcliffe KM. Hospitals as Cultures of Entrapment: A Re-Analysis of the Bristol Royal Infirmary. Calif Manage Rev. 2012;45(2):73-84. doi:10.2307/41166166. https://psnet.ahrq.gov/issue/hospitals-cultures-en…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47519/psn-pdf
    February 22, 2019 - Simulation-based education to train learners to "speak up" in the clinical environment: results of a randomized trial. February 22, 2019 Oner C, Fisher N, Atallah F, et al. Simulation-Based Education to Train Learners to "Speak Up" in the Clinical Environment: Results of a Randomized Trial. Simul Healthc. 2018;13(…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44730/psn-pdf
    December 08, 2015 - Why studying human behavior is a critical component of patient safety. December 8, 2015 Su L. Why Studying Human Behavior is a Critical Component of Patient Safety. Curr Probl Pediatr Adolesc Health Care. 2015;45(12):367-9. doi:10.1016/j.cppeds.2015.10.004. https://psnet.ahrq.gov/issue/why-studying-human-behavior-…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36947/psn-pdf
    September 09, 2011 - The safety of warfarin therapy in the nursing home setting. September 9, 2011 Gurwitz JH, Field T, Radford MJ, et al. The safety of warfarin therapy in the nursing home setting. Am J Med. 2007;120(6):539-44. https://psnet.ahrq.gov/issue/safety-warfarin-therapy-nursing-home-setting The anticoagulant warfarin is co…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41607/psn-pdf
    January 03, 2017 - Using a risk assessment approach to determine which factors influence whether partially bilingual physicians rely on their non-English language skills or call an interpreter. January 3, 2017 Maul L, Regenstein M, Andres E, et al. Using a risk assessment approach to determine which factors influence whether partia…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44361/psn-pdf
    November 20, 2015 - Communication in healthcare: a narrative review of the literature and practical recommendations. November 20, 2015 Vermeir P, Vandijck D, Degroote S, et al. Communication in healthcare: a narrative review of the literature and practical recommendations. Int J Clin Pract. 2015;69(11):1257-67. doi:10.1111/ijcp.12686.…
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