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Showing results for "failures".

  1. More than half a million heart surgery patients at risk of a dangerous infection. | PSNet

    psnet.ahrq.gov/issue/more-half-million-heart-surgery-patients-risk-dangerous-infection
    April 22, 2015 - Newspaper/Magazine Article More than half a million heart surgery patients at risk of a dangerous infection. Citation Text: More than half a million heart surgery patients at risk of a dangerous infection. Sun LH. Copy Citation Save Save to your library Prin…

  2. An interview with Audrey Nelson. Interviewed by Steven Berman. | PSNet

    psnet.ahrq.gov/issue/interview-audrey-nelson-interviewed-steven-berman
    January 19, 2022 - Commentary An interview with Audrey Nelson. Interviewed by Steven Berman. Citation Text: Nelson AL. An interview with Audrey Nelson. Interviewed by Steven Berman. Jt Comm J Qual Patient Saf. 2005;31(12):665-670. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 …

  3. Patient engagement in patient safety: barriers and facilitators. | PSNet

    psnet.ahrq.gov/issue/patient-engagement-patient-safety-barriers-and-facilitators
    May 09, 2015 - Newspaper/Magazine Article Patient engagement in patient safety: barriers and facilitators. Citation Text: Patient engagement in patient safety: barriers and facilitators. Scobie AC, Persaud DD. Patient Saf Qual Healthc. March/April 2010;7:42-47. Copy Citation Save …

  4. Person-Centered Guidelines for Preserving Family Presence in Challenging Times. | PSNet

    psnet.ahrq.gov/issue/person-centered-guidelines-preserving-family-presence-challenging-times
    October 14, 2015 - Book/Report Person-Centered Guidelines for Preserving Family Presence in Challenging Times. Citation Text: Person-Centered Guidelines for Preserving Family Presence in Challenging Times. Derby, CT: Planetree; 2020. Copy Citation Save Save to your library P…

  5. The MacArthur Fellows Program: Peter Pronovost. | PSNet

    psnet.ahrq.gov/issue/macarthur-fellows-program-peter-pronovost
    June 11, 2013 - Press Release/Announcement The MacArthur Fellows Program: Peter Pronovost. Citation Text: The MacArthur Fellows Program: Peter Pronovost. The John D. and Catherine T. MacArthur Foundation. Copy Citation Save Save to your library Print Download PDF …

  6. Methodology | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/final-reports/ptmgmt/methodology.html
    July 01, 2018 - Patient Self-Management Support Programs: An Evaluation Methodology Previous Page Next Page Table of Contents Patient Self-Management Support Programs: An Evaluation Acknowledgments Introduction and Purpose Summary Background Methodology Design Options for a Self-Management Support Progr…

  7. Introduction and Purpose | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/final-reports/ptmgmt/introduction.html
    July 01, 2018 - Patient Self-Management Support Programs: An Evaluation Introduction and Purpose Previous Page Next Page Table of Contents Patient Self-Management Support Programs: An Evaluation Acknowledgments Introduction and Purpose Summary Background Methodology Design Options for a Self-Management …

  8. Despite technology, verbal orders persist, read back is not widespread, and errors continue. | PSNet

    psnet.ahrq.gov/issue/despite-technology-verbal-orders-persist-read-back-not-widespread-and-errors-continue
    June 28, 2017 - Newspaper/Magazine Article Despite technology, verbal orders persist, read back is not widespread, and errors continue. Citation Text: Despite technology, verbal orders persist, read back is not widespread, and errors continue. ISMP Medication Safety Alert! Acute Care Edition. May 18, 20…

  9. SBAR for patients. | PSNet

    psnet.ahrq.gov/issue/sbar-patients
    September 12, 2012 - Commentary SBAR for patients. Citation Text: Denham CR. SBAR for Patients. J Patient Saf. 2008;4(1). doi:10.1097/pts.0b013e2181660c06. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation …

  10. Reviewing the Team's Performance: Debrief | Agency for Healthcare Research and Quality

    www.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.html
    December 01, 2023 - Reviewing the Team's Performance: Debrief Research has shown that teams that effectively debrief their own performance can improve their teamwork in real time. 1 , 2 , 3 , 4   Although it is often difficult to find time for such reviews in healthcare, TeamSTEPPS advocates for after-action reviews; TeamSTEPPS ch…

  11. Will saying "I'm sorry" prevent a malpractice lawsuit? | PSNet

    psnet.ahrq.gov/issue/will-saying-im-sorry-prevent-malpractice-lawsuit
    October 23, 2018 - Commentary Will saying "I'm sorry" prevent a malpractice lawsuit? Citation Text: Berlin L. Will Saying "I'm Sorry" Prevent a Malpractice Lawsuit? AJR Am J Roentgenol. 2006;187(1):10-5. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

  12. Tenfold errors can lead to tragedy. | PSNet

    psnet.ahrq.gov/issue/tenfold-errors-can-lead-tragedy
    February 21, 2007 - Newspaper/Magazine Article Tenfold errors can lead to tragedy. Citation Text: Tenfold errors can lead to tragedy. Sipkoff M. Drug Topics. August 21, 2006. Copy Citation Save Save to your library Print Download PDF Share Facebook Twit…

  13. Care Compare. | PSNet

    psnet.ahrq.gov/issue/care-compare
    May 26, 2021 - Multi-use Website Care Compare. Citation Text: Care Compare. Centers for Medicare and Medicaid Services. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL J…

  14. Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events. | PSNet

    psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and-corrective-action
    November 27, 2018 - Book/Report Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events. Citation Text: Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events. Oakbroo…

  15. C1 Prioritization Worksheet (xls file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheet.xlsx
    June 02, 2025 - C1 Prioritization Worksheet Prioritization Worksheet Pediatric Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety AHRQ Pediatric Quality Indicators Prioritization Worksheet Section 1- Blue Section 2-Green Section 3-Purple Section 4-Orange Own Rate a…

  16. Potassium may no longer be stocked on patient care units, but serious threats still exist! | PSNet

    psnet.ahrq.gov/issue/potassium-may-no-longer-be-stocked-patient-care-units-serious-threats-still-exist
    May 02, 2018 - Newspaper/Magazine Article Potassium may no longer be stocked on patient care units, but serious threats still exist! Citation Text: Potassium may no longer be stocked on patient care units, but serious threats still exist! ISMP Medication Safety Alert! Acute care edition. October 4, 200…

  17. Human Error. | PSNet

    psnet.ahrq.gov/issue/human-error
    March 06, 2005 - Book/Report Classic Human Error. Citation Text: Human Error. Reason JT. Cambridge, UK: Cambridge University Press; 1990. ISBN: 9780521306690. Copy Citation Save Save to your library Print Download PDF Share Facebook …

  18. Eliminating insulin errors: RPhs share tricks.  | PSNet

    psnet.ahrq.gov/issue/eliminating-insulin-errors-rphs-share-tricks
    June 13, 2011 - Newspaper/Magazine Article Eliminating insulin errors: RPhs share tricks.  Citation Text: Eliminating insulin errors: RPhs share tricks.  Cassell D. Drug Topics. March 20, 2006. Copy Citation Save Save to your library Print Download PDF Share…

  19. Quality Measurement | Digital Healthcare Research

    digital.ahrq.gov/health-care-theme/quality-measurement
    January 01, 2023 - Quality Measurement Complexity, Incidence, and Costs Related to Delayed Diagnosis of Venous Thromboembolism in Urban and Rural Primary and Urgent Care Settings Description This research aims to improve the early detection of venous thromboembolism in primary and urgent care by…

  20. Beware of basal opioid infusions with PCA therapy. | PSNet

    psnet.ahrq.gov/issue/beware-basal-opioid-infusions-pca-therapy
    June 05, 2018 - Newspaper/Magazine Article Beware of basal opioid infusions with PCA therapy. Citation Text: Beware of basal opioid infusions with PCA therapy. ISMP Medication Safety Alert! Acute Care Edition. March 12, 2009;14:1-3. Copy Citation Save Save to your library P…
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