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Showing results for "failures".

  1. Unintended consequences of the electronic health record and cognitive load in emergency department nurses. | PSNet

    psnet.ahrq.gov/issue/unintended-consequences-electronic-health-record-and-cognitive-load-emergency-department
    June 22, 2011 - Study Unintended consequences of the electronic health record and cognitive load in emergency department nurses. Citation Text: Harmon CS, Adams SA, Davis JE, et al. Unintended consequences of the electronic health record and cognitive load in emergency department nurses. Appl Nurs Res. …

  2. Delayed Admissions to the Pediatric Intensive Care Unit: Progression of Disease or Errors in Emergency Department Management | PSNet

    psnet.ahrq.gov/issue/delayed-admissions-pediatric-intensive-care-unit-progression-disease-or-errors-emergency
    June 14, 2019 - Journal Article Delayed Admissions to the Pediatric Intensive Care Unit: Progression of Disease or Errors in Emergency Department Management Citation Text: Czolgosz T, Cashen K, Farooqi A, et al. Delayed Admissions to the Pediatric Intensive Care Unit: Progression of Disease or Errors in…

  3. Factors associated with adverse events resulting from medical errors in the emergency department: two work better than one. | PSNet

    psnet.ahrq.gov/issue/factors-associated-adverse-events-resulting-medical-errors-emergency-department-two-work
    July 02, 2019 - Study Factors associated with adverse events resulting from medical errors in the emergency department: two work better than one. Citation Text: Freund Y, Goulet H, Bokobza J, et al. Factors associated with adverse events resulting from medical errors in the emergency department: two w…

  4. Ventilator-related adverse events: a taxonomy and findings from 3 incident reporting systems. | PSNet

    psnet.ahrq.gov/issue/ventilator-related-adverse-events-taxonomy-and-findings-3-incident-reporting-systems
    March 01, 2017 - Study Ventilator-related adverse events: a taxonomy and findings from 3 incident reporting systems. Citation Text: Pham JC, Williams TL, Sparnon EM, et al. Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems. Respir Care. 2016;61(5):621-31. doi:10…

  5. Cognitive biases and moral characteristics of healthcare workers and their treatment approach for persons with advanced dementia in acute care settings. | PSNet

    psnet.ahrq.gov/issue/cognitive-biases-and-moral-characteristics-healthcare-workers-and-their-treatment-approach
    March 28, 2018 - Study Cognitive biases and moral characteristics of healthcare workers and their treatment approach for persons with advanced dementia in acute care settings. Citation Text: Erel M, Marcus E-L, DeKeyser Ganz F. Cognitive biases and moral characteristics of healthcare workers and their tr…

  6. Medication errors in hospitalised children. | PSNet

    psnet.ahrq.gov/issue/medication-errors-hospitalised-children
    September 03, 2014 - Study Medication errors in hospitalised children. Citation Text: Manias E, Kinney S, Cranswick N, et al. Medication errors in hospitalised children. J Paediatr Child Health. 2014;50(1):71-7. doi:10.1111/jpc.12412. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndN…

  7. Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine? | PSNet

    psnet.ahrq.gov/issue/fatal-consequences-simple-mistake-how-can-patient-be-saved-inadvertent-intrathecal
    January 29, 2020 - Commentary Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine? Citation Text: Reddy K, Brown B, Nanda A. Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine? Clin Neurol Neu…

  8. What can apologies in the electronic health record tell us about health care quality, processes, and safety? | PSNet

    psnet.ahrq.gov/issue/what-can-apologies-electronic-health-record-tell-us-about-health-care-quality-processes-and
    November 18, 2016 - Study What can apologies in the electronic health record tell us about health care quality, processes, and safety? Citation Text: Matulis JC, North F. What Can Apologies in the Electronic Health Record Tell Us About Health Care Quality, Processes, and Safety? J Patient Saf. 2020;16(3):e1…

  9. Optimizing smart pump technology by increasing critical safety alerts and reducing clinically insignificant alerts. | PSNet

    psnet.ahrq.gov/issue/optimizing-smart-pump-technology-increasing-critical-safety-alerts-and-reducing-clinically
    February 12, 2014 - Study Optimizing smart pump technology by increasing critical safety alerts and reducing clinically insignificant alerts. Citation Text: Mansfield J, Jarrett S. Optimizing smart pump technology by increasing critical safety alerts and reducing clinically insignificant alerts. Hosp Pharm.…

  10. Comparison of clinical diagnoses and autopsy findings: six-year retrospective study. | PSNet

    psnet.ahrq.gov/issue/comparison-clinical-diagnoses-and-autopsy-findings-six-year-retrospective-study
    March 27, 2024 - Study Comparison of clinical diagnoses and autopsy findings: six-year retrospective study. Citation Text: Marshall HS, Milikowski C. Comparison of clinical diagnoses and autopsy findings: six-year retrospective study. Arch Pathol Lab Med. 2017;141(9):1262-1266. doi:10.5858/arpa.2016-0488…

  11. Implementation of medication error reporting through Med Safe Tool: the clinical pharmacists and the inpatient nursing staff collaborative approach. | PSNet

    psnet.ahrq.gov/issue/implementation-medication-error-reporting-through-med-safe-tool-clinical-pharmacists-and
    December 16, 2011 - Study Implementation of medication error reporting through Med Safe Tool: the clinical pharmacists and the inpatient nursing staff collaborative approach. Citation Text: Elnour AA, Ellahham NH, Al Qassas HI. Implementation of Medication Error Reporting Through Med Safe Tool. J Patient …

  12. Medical emergency team calls in the radiology department: patient characteristics and outcomes. | PSNet

    psnet.ahrq.gov/issue/medical-emergency-team-calls-radiology-department-patient-characteristics-and-outcomes
    July 06, 2011 - Study Medical emergency team calls in the radiology department: patient characteristics and outcomes. Citation Text: Ott LK, Pinsky MR, Hoffman LA, et al. Medical emergency team calls in the radiology department: patient characteristics and outcomes. BMJ Qual Saf. 2012;21(6):509-18. d…

  13. Vital sign abnormalities, rapid response, and adverse outcomes in hospitalized patients. | PSNet

    psnet.ahrq.gov/issue/vital-sign-abnormalities-rapid-response-and-adverse-outcomes-hospitalized-patients
    December 21, 2014 - Study Vital sign abnormalities, rapid response, and adverse outcomes in hospitalized patients. Citation Text: Fagan K, Sabel A, Mehler PS, et al. Vital sign abnormalities, rapid response, and adverse outcomes in hospitalized patients. Am J Med Qual. 2012;27(6):480-6. doi:10.1177/1062860…

  14. Older veterans and emergency department discharge information. | PSNet

    psnet.ahrq.gov/issue/older-veterans-and-emergency-department-discharge-information
    March 02, 2011 - Study Older veterans and emergency department discharge information. Citation Text: Hastings S, Stechuchak K, Oddone E, et al. Older veterans and emergency department discharge information. BMJ Qual Saf. 2012;21(10):835-42. Copy Citation Format: Google Scholar PubMed BibT…

  15. Identifying and reducing distractions and interruptions in a pharmacy department. | PSNet

    psnet.ahrq.gov/issue/identifying-and-reducing-distractions-and-interruptions-pharmacy-department
    August 22, 2015 - Study Identifying and reducing distractions and interruptions in a pharmacy department. Citation Text: Raimbault M, Guérin A, Caron E, et al. Identifying and reducing distractions and interruptions in a pharmacy department. Am J Health Syst Pharm. 2013;70(3):186, 188, 190. doi:10.2146/aj…

  16. Accidental iatrogenic pneumothorax in hospitalized patients. | PSNet

    psnet.ahrq.gov/issue/accidental-iatrogenic-pneumothorax-hospitalized-patients
    April 03, 2005 - Study Accidental iatrogenic pneumothorax in hospitalized patients. Citation Text: Zhan C, Smith M, Stryer D. Accidental iatrogenic pneumothorax in hospitalized patients. Med Care. 2006;44(2):182-186. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNot…

  17. Disclosing errors and adverse events in the intensive care unit. | PSNet

    psnet.ahrq.gov/issue/disclosing-errors-and-adverse-events-intensive-care-unit
    February 17, 2017 - Study Disclosing errors and adverse events in the intensive care unit. Citation Text: Boyle DJ, O'Connell D, Platt FW, et al. Disclosing errors and adverse events in the intensive care unit. Crit Care Med. 2006;34(5):1532-7. Copy Citation Format: Google Scholar PubMed Bib…

  18. Raising the awareness of inpatient nursing staff about medication errors. | PSNet

    psnet.ahrq.gov/issue/raising-awareness-inpatient-nursing-staff-about-medication-errors
    February 15, 2011 - Study Raising the awareness of inpatient nursing staff about medication errors. Citation Text: Elnour AA, Ellahham NH, Qassas HIA. Raising the awareness of inpatient nursing staff about medication errors. Pharm World Sci. 2008;30(2):182-90. Copy Citation Format: Google Sc…

  19. New world of patient safety. 23rd Annual Samuel Jason Mixter Lecture. | PSNet

    psnet.ahrq.gov/issue/new-world-patient-safety-23rd-annual-samuel-jason-mixter-lecture
    November 02, 2014 - Commentary New world of patient safety. 23rd Annual Samuel Jason Mixter Lecture. Citation Text: Leape L. New world of patient safety: 23rd Annual Samuel Jason Mixter lecture. Arch Surg. 2009;144(5):394-8. doi:10.1001/archsurg.2009.78. Copy Citation Format: DOI Google Schola…

  20. Use of the WHO surgical safety checklist in trauma and orthopaedic patients. | PSNet

    psnet.ahrq.gov/issue/use-who-surgical-safety-checklist-trauma-and-orthopaedic-patients
    August 30, 2017 - Study Use of the WHO surgical safety checklist in trauma and orthopaedic patients. Citation Text: Sewell M, Adebibe M, Jayakumar P, et al. Use of the WHO surgical safety checklist in trauma and orthopaedic patients. Int Orthop. 2011;35(6):897-901. doi:10.1007/s00264-010-1112-7. Copy …
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