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Showing results for "failures".

  1. Building collaborative teams in neonatal intensive care. | PSNet

    psnet.ahrq.gov/issue/building-collaborative-teams-neonatal-intensive-care
    August 14, 2019 - Study Building collaborative teams in neonatal intensive care. Citation Text: Brodsky D, Gupta M, Quinn M, et al. Building collaborative teams in neonatal intensive care. BMJ Qual Saf. 2013;22(5):374-82. doi:10.1136/bmjqs-2012-000909. Copy Citation Format: DOI Google Scho…

  2. Defining and classifying terminology for medication harm: a call for consensus. | PSNet

    psnet.ahrq.gov/issue/defining-and-classifying-terminology-medication-harm-call-consensus
    June 22, 2022 - Review Defining and classifying terminology for medication harm: a call for consensus. Citation Text: Falconer N, Barras M, Martin J, et al. Defining and classifying terminology for medication harm: a call for consensus. Eur J Clin Pharmacol. 2019;75(2):137-145. doi:10.1007/s00228-018-25…

  3. Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors. | PSNet

    psnet.ahrq.gov/issue/exploring-potential-using-drug-indications-prevent-look-alike-and-sound-alike-drug-errors
    December 18, 2019 - Study Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors. Citation Text: Seoane-Vazquez E, Rodriguez-Monguio R, Alqahtani S, et al. Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors. Expe…

  4. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. | PSNet

    psnet.ahrq.gov/issue/using-six-sigma-reduce-medication-errors-home-delivery-pharmacy-service
    November 18, 2015 - Study Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Citation Text: Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24. Copy Citation …

  5. Chemotherapeutic errors in hospitalised cancer patients: attributable damage and extra costs. | PSNet

    psnet.ahrq.gov/issue/chemotherapeutic-errors-hospitalised-cancer-patients-attributable-damage-and-extra-costs
    May 04, 2012 - Study Chemotherapeutic errors in hospitalised cancer patients: attributable damage and extra costs. Citation Text: Ranchon F, Salles G, Späth H-M, et al. Chemotherapeutic errors in hospitalised cancer patients: attributable damage and extra costs. BMC Cancer. 2011;11:478. doi:10.1186/1…

  6. Telehealth safety framework: addressing a new frontier in patient safety. | PSNet

    psnet.ahrq.gov/issue/telehealth-safety-framework-addressing-new-frontier-patient-safety
    December 21, 2022 - Commentary Telehealth safety framework: addressing a new frontier in patient safety. Citation Text: Gomes KM, Apathy N, Krevat SA, et al. Telehealth safety framework: addressing a new frontier in patient safety. J Patient Saf. 2024;20(5):358-359. doi:10.1097/pts.0000000000001243. Copy …

  7. Factors associated with emergency department visits and hospital admissions after invasive outpatient procedures in the Veterans Health Administration. | PSNet

    psnet.ahrq.gov/issue/factors-associated-emergency-department-visits-and-hospital-admissions-after-invasive
    August 17, 2018 - Study Factors associated with emergency department visits and hospital admissions after invasive outpatient procedures in the Veterans Health Administration. Citation Text: Mull HJ, Gellad ZF, Gupta RT, et al. Factors Associated With Emergency Department Visits and Hospital Admissions Af…

  8. The "July phenomenon": is trauma the exception? | PSNet

    psnet.ahrq.gov/issue/july-phenomenon-trauma-exception
    January 15, 2014 - Study The "July phenomenon": is trauma the exception? Citation Text: Schroeppel TJ, Fischer PE, Magnotti LJ, et al. The "July phenomenon": is trauma the exception? J Am Coll Surg. 2009;209(3):378-84. doi:10.1016/j.jamcollsurg.2009.05.026. Copy Citation Format: DOI Google …

  9. Surgical patient safety officers in the United States: negotiating contradictions between compliance and workplace transformation. | PSNet

    psnet.ahrq.gov/issue/surgical-patient-safety-officers-united-states-negotiating-contradictions-between-compliance
    December 31, 2018 - Commentary Surgical patient safety officers in the United States: negotiating contradictions between compliance and workplace transformation. Citation Text: van de Ruit C, Bosk CL. Surgical patient safety officers in the United States: negotiating contradictions between compliance and wo…

  10. Teamwork, communication and safety climate: a systematic review of interventions to improve surgical culture. | PSNet

    psnet.ahrq.gov/issue/teamwork-communication-and-safety-climate-systematic-review-interventions-improve-surgical
    May 26, 2016 - Review Teamwork, communication and safety climate: a systematic review of interventions to improve surgical culture. Citation Text: Sacks GD, Shannon EM, Dawes AJ, et al. Teamwork, communication and safety climate: a systematic review of interventions to improve surgical culture. BMJ Qua…

  11. Medication errors: an important component of nonadherence to medication in an outpatient population of lung transplant recipients. | PSNet

    psnet.ahrq.gov/issue/medication-errors-important-component-nonadherence-medication-outpatient-population-lung
    June 23, 2021 - Study Medication errors: an important component of nonadherence to medication in an outpatient population of lung transplant recipients. Citation Text: Irani S, Seba P, Speich R, et al. Medication errors: an important component of nonadherence to medication in an outpatient population …

  12. Root cause analysis of ambulatory adverse drug events that present to the emergency department. | PSNet

    psnet.ahrq.gov/issue/root-cause-analysis-ambulatory-adverse-drug-events-present-emergency-department
    April 25, 2016 - Study Root cause analysis of ambulatory adverse drug events that present to the emergency department. Citation Text: Gertler SA, Coralic Z, Lopez A, et al. Root Cause Analysis of Ambulatory Adverse Drug Events That Present to the Emergency Department. J Patient Saf. 2014;12(3). doi:10.10…

  13. Effect of an anonymous reporting system on near-miss and harmful medical error reporting in a pediatric intensive care unit. | PSNet

    psnet.ahrq.gov/issue/effect-anonymous-reporting-system-near-miss-and-harmful-medical-error-reporting-pediatric
    September 28, 2010 - Study Effect of an anonymous reporting system on near-miss and harmful medical error reporting in a pediatric intensive care unit. Citation Text: Grant MJC, Larsen G. Effect of an anonymous reporting system on near-miss and harmful medical error reporting in a pediatric intensive care …

  14. Implementation of a pediatric rapid response team: experience of the Hospital for Sick Children in Toronto. | PSNet

    psnet.ahrq.gov/issue/implementation-pediatric-rapid-response-team-experience-hospital-sick-children-toronto
    September 10, 2014 - Commentary Implementation of a pediatric rapid response team: experience of the Hospital for Sick Children in Toronto. Citation Text: Kukreti V, Gaiteiro R, Mohseni-Bod H. Implementation of a pediatric rapid response team: experience of the Hospital for Sick Children in Toronto. Indian …

  15. The alarming reality of medication error: a patient case and review of Pennsylvania and national data. | PSNet

    psnet.ahrq.gov/issue/alarming-reality-medication-error-patient-case-and-review-pennsylvania-and-national-data
    June 28, 2017 - Commentary The alarming reality of medication error: a patient case and review of Pennsylvania and national data. Citation Text: 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 Me…

  16. Liability impact of the hospitalist model of care. | PSNet

    psnet.ahrq.gov/issue/liability-impact-hospitalist-model-care
    July 09, 2018 - Study Liability impact of the hospitalist model of care. Citation Text: Schaffer A, Puopolo AL, Raman S, et al. Liability impact of the hospitalist model of care. J Hosp Med. 2014;9(12):750-5. doi:10.1002/jhm.2244. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndN…

  17. Patient and family engagement: a survey of US hospital practices. | PSNet

    psnet.ahrq.gov/issue/patient-and-family-engagement-survey-us-hospital-practices
    January 02, 2017 - Study Patient and family engagement: a survey of US hospital practices. Citation Text: Herrin J, Harris KG, Kenward K, et al. Patient and family engagement: a survey of US hospital practices. BMJ Qual Saf. 2016;25(3):182-9. doi:10.1136/bmjqs-2015-004006. Copy Citation Format: …

  18. What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings. | PSNet

    psnet.ahrq.gov/issue/what-would-you-ideally-do-if-there-were-no-targets-ethnographic-study-unintended-consequences
    July 27, 2011 - Study What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings. Citation Text: Allard J, Bleakley A. What would you ideally do if there were no targets? An ethnographic study of the unintended…

  19. Emotional exhaustion and workload predict clinician-rated and objective patient safety. | PSNet

    psnet.ahrq.gov/issue/emotional-exhaustion-and-workload-predict-clinician-rated-and-objective-patient-safety
    February 14, 2017 - Study Emotional exhaustion and workload predict clinician-rated and objective patient safety. Citation Text: Welp A, Meier LL, Manser T. Emotional exhaustion and workload predict clinician-rated and objective patient safety. Front Psychol. 2014;5:1573. doi:10.3389/fpsyg.2014.01573. Cop…

  20. Responding to serious medical error in general practice—consequences for the GPs involved: analysis of 75 cases from Germany. | PSNet

    psnet.ahrq.gov/issue/responding-serious-medical-error-general-practice-consequences-gps-involved-analysis-75-cases
    June 19, 2019 - Study Responding to serious medical error in general practice—consequences for the GPs involved: analysis of 75 cases from Germany. Citation Text: Fisseni G, Pentzek M, Abholz H-H. Responding to serious medical error in general practice--consequences for the GPs involved: analysis of 7…
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