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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849134/psn-pdf
    May 17, 2023 - Adverse patient safety events during the COVID epidemic. May 17, 2023 Yackel EE, Knowles RS, Jones CM, et al. Adverse patient safety events during the COVID epidemic. J Patient Saf. 2023;19(5):340-345. doi:10.1097/pts.0000000000001129. https://psnet.ahrq.gov/issue/adverse-patient-safety-events-during-covid-epidemic…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860394/psn-pdf
    January 10, 2024 - Respectful Maternity Care: Dissemination and Implementation of Perinatal Safety Culture to Improve Equitable Maternal Healthcare Delivery and Outcomes. January 10, 2024 Respectful Maternity Care: Dissemination and Implementation of Perinatal Safety Culture To Improve Equitable Maternal Healthcare Delivery and Outc…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60045/psn-pdf
    March 18, 2020 - Making Healthcare Safer III. March 18, 2020 Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF. https://psnet.ahrq.gov/issue/making-healthcare-safer-iii This newly issued follow up to the seminal AHRQ Making Health Care Safer rep…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46606/psn-pdf
    July 10, 2019 - Implementation of a mock root cause analysis to provide simulated patient safety training. July 10, 2019 Murphy M, Duff J, Whitney J, et al. Implementation of a mock root cause analysis to provide simulated patient safety training. BMJ Open Qual. 2017;6(2). doi:10.1136/bmjoq-2017-000096. https://psnet.ahrq.gov/iss…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46168/psn-pdf
    June 14, 2017 - The HOSPITAL score predicts potentially preventable 30- day readmissions in conditions targeted by the Hospital Readmissions Reduction Program. June 14, 2017 Burke RE, Schnipper JL, Williams M, et al. The HOSPITAL Score Predicts Potentially Preventable 30-Day Readmissions in Conditions Targeted by the Hospital Rea…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45605/psn-pdf
    November 30, 2016 - Advancing interprofessional patient safety education for medical, nursing, and pharmacy learners during clinical rotations. November 30, 2016 Thom KA, Heil EL, Croft LD, et al. Advancing interprofessional patient safety education for medical, nursing, and pharmacy learners during clinical rotations. J Interprof Ca…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47376/psn-pdf
    November 02, 2018 - Assessing information sources to elucidate diagnostic process errors in radiologic imaging—a human factors framework. November 2, 2018 Cochon L, Lacson R, Wang A, et al. Assessing information sources to elucidate diagnostic process errors in radiologic imaging - a human factors framework. J Am Med Info Asso. 2018;…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848366/psn-pdf
    May 03, 2023 - The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services. May 3, 2023 Ward CE, Taylor M, Keeney C, et al. The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services. Prehosp Emerg Care. 2…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853431/psn-pdf
    September 13, 2023 - Diagnostic errors in uncommon conditions: a systematic review of case reports of diagnostic errors. September 13, 2023 Harada Y, Watari T, Nagano H, et al. Diagnostic errors in uncommon conditions: a systematic review of case reports of diagnostic errors. Diagnosis (Berl). 2023;10(4):329-336. doi:10.1515/dx-2023-00…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47952/psn-pdf
    January 01, 2020 - Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature. May 15, 2019 Thonon H, Espeel F, Frederic F, et al. Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature. Acta Clin Belg. 2020;75(3…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44089/psn-pdf
    April 22, 2015 - Learning from mistakes and near mistakes: using root cause analysis as a risk management tool. April 22, 2015 Cerniglia-Lowensen J. Learning From Mistakes and Near Mistakes: Using Root Cause Analysis as a Risk Management Tool. J Radiol Nurs. 2015;34(1). doi:10.1016/j.jradnu.2014.11.004. https://psnet.ahrq.gov/issu…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44047/psn-pdf
    September 09, 2015 - Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record. September 9, 2015 Dalal A, Pesterev BM, Eibensteiner K, et al. Linking acknowledgement to action: closing the loop on non- urgent, clinically significant test results in the elect…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45510/psn-pdf
    October 19, 2016 - How to perform a root cause analysis for workup and future prevention of medical errors: a review. October 19, 2016 Charles R, Hood B, DeRosier JM, et al. How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient Saf Surg. 2016;10:20. doi:10.1186/s13037-016-0107-8. …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44257/psn-pdf
    November 06, 2015 - A systems approach to evaluating ionizing radiation: six focus areas to improve quality, efficiency, and patient safety. November 6, 2015 Perlin JB, Mower L, Bushe C. A systems approach to evaluating ionizing radiation: six focus areas to improve quality, efficiency, and patient safety. J Healthc Qual. 2015;37(3):…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47748/psn-pdf
    June 14, 2019 - The impact of health information technology on the management and follow-up of test results—a systematic review. June 14, 2019 Georgiou A, Li J, Thomas J, et al. The impact of health information technology on the management and follow-up of test results - a systematic review. J Am Med Inform Assoc. 2019;26(7):678-…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73067/psn-pdf
    March 24, 2021 - Changes in error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths. March 24, 2021 LaGrone LN, McIntyre LK, Riggle A, et al. Changes in error patterns in unanticipated trauma deaths during 20 years: In pursuit of zero preventable deaths. J Trauma Acute Care Surg. 2020;89…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837308/psn-pdf
    June 01, 2022 - Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement. June 1, 2022 Politi RE, Mills PD, Zubkoff L, et al. Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement. J Patient Saf. 2022;1…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40145/psn-pdf
    November 14, 2011 - Postoperative sepsis in the United States. November 14, 2011 Vogel TR, Dombrovskiy VY, Carson JL, et al. Postoperative sepsis in the United States. Ann Surg. 2010;252(6):1065-71. doi:10.1097/SLA.0b013e3181dcf36e. https://psnet.ahrq.gov/issue/postoperative-sepsis-united-states The safety of patients undergoing surg…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47508/psn-pdf
    October 24, 2018 - Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. October 24, 2018 Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.1002/aorn.12372. https://psnet.ahrq.go…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837743/psn-pdf
    July 27, 2022 - The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm. July 27, 2022 Washington, DC: VA Office of the Inspector General; July 14 2022. Report No. 22-01137-204. https://psnet.ahrq.gov/issue/new-electronic-health-records-unknown-queue-caused-multiple-events-patient- harm Problems w…
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