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Showing results for "failures".

  1. Experiences with Lean Six Sigma as improvement strategy to reduce parenteral medication administration errors and associated potential risk of harm. | PSNet

    psnet.ahrq.gov/issue/experiences-lean-six-sigma-improvement-strategy-reduce-parenteral-medication-administration
    October 13, 2021 - Commentary Experiences with Lean Six Sigma as improvement strategy to reduce parenteral medication administration errors and associated potential risk of harm. Citation Text: van de Plas A, Slikkerveer M, Hoen S, et al. Experiences with Lean Six Sigma as improvement strategy to reduce pa…

  2. Diagnosing fast and slow: cognitive bias in obstetrics. | PSNet

    psnet.ahrq.gov/issue/diagnosing-fast-and-slow-cognitive-bias-obstetrics
    February 22, 2019 - Commentary Diagnosing fast and slow: cognitive bias in obstetrics. Citation Text: Atallah F, Gomes C, Minkoff H. Diagnosing fast and slow: cognitive bias in obstetrics. Obstet Gynecol. 2023;142(3):727-732. doi:10.1097/aog.0000000000005303. Copy Citation Format: DOI Google S…

  3. Evaluating the potential severity of look-alike, sound-alike drug substitution errors in children. | PSNet

    psnet.ahrq.gov/issue/evaluating-potential-severity-look-alike-sound-alike-drug-substitution-errors-children
    July 16, 2015 - Study Evaluating the potential severity of look-alike, sound-alike drug substitution errors in children. Citation Text: Basco WT, Garner SS, Ebeling M, et al. Evaluating the Potential Severity of Look-Alike, Sound-Alike Drug Substitution Errors in Children. Acad Pediatr. 2016;16(2):183-1…

  4. Can a structured checklist prevent problems with laparoscopic equipment? | PSNet

    psnet.ahrq.gov/issue/can-structured-checklist-prevent-problems-laparoscopic-equipment
    August 10, 2016 - Study Can a structured checklist prevent problems with laparoscopic equipment? Citation Text: Verdaasdonk EGG, Stassen LPS, Hoffmann WF, et al. Can a structured checklist prevent problems with laparoscopic equipment? Surg Endosc. 2008;22(10):2238-43. doi:10.1007/s00464-008-0029-3. Co…

  5. Pharmacists in pharmacovigilance: can increased diagnostic opportunity in community settings translate to better vigilance? | PSNet

    psnet.ahrq.gov/issue/pharmacists-pharmacovigilance-can-increased-diagnostic-opportunity-community-settings
    July 26, 2023 - Commentary Pharmacists in pharmacovigilance: can increased diagnostic opportunity in community settings translate to better vigilance? Citation Text: Rutter P, Brown D, Howard J, et al. Pharmacists in pharmacovigilance: can increased diagnostic opportunity in community settings translate…

  6. Recognition and prevention of nosocomial malnutrition: a review and a call to action! | PSNet

    psnet.ahrq.gov/issue/recognition-and-prevention-nosocomial-malnutrition-review-and-call-action
    January 29, 2020 - Review Recognition and prevention of nosocomial malnutrition: a review and a call to action! Citation Text: Kirkland LL, Shaughnessy E. Recognition and Prevention of Nosocomial Malnutrition: A Review and A Call to Action!. Am J Med. 2017;130(12):1345-1350. doi:10.1016/j.amjmed.2017.07.03…

  7. Perioperative safety in plastic surgery: is the World Health Organization checklist useful in a broad practice? | PSNet

    psnet.ahrq.gov/issue/perioperative-safety-plastic-surgery-world-health-organization-checklist-useful-broad
    September 23, 2020 - Study Perioperative safety in plastic surgery: is the World Health Organization checklist useful in a broad practice? Citation Text: Biskup N, Workman AD, Kutzner E, et al. Perioperative Safety in Plastic Surgery: Is the World Health Organization Checklist Useful in a Broad Practice? Ann…

  8. E-learning on risk management. An opportunity for sharing knowledge and experiences in patient safety. | PSNet

    psnet.ahrq.gov/issue/e-learning-risk-management-opportunity-sharing-knowledge-and-experiences-patient-safety
    November 18, 2020 - Commentary E-learning on risk management. An opportunity for sharing knowledge and experiences in patient safety. Citation Text: Agra Y, García-Álvarez V, Aibar-Remón C, et al. E-learning on risk management. An opportunity for sharing knowledge and experiences in patient safety. Int J He…

  9. Detection of potential look-alike/sound-alike medication errors using Veterans Affairs administrative databases. | PSNet

    psnet.ahrq.gov/issue/detection-potential-look-alikesound-alike-medication-errors-using-veterans-affairs
    October 04, 2011 - Study Detection of potential look-alike/sound-alike medication errors using Veterans Affairs administrative databases. Citation Text: Zacher JM, Cunningham FE, Zhao X, et al. Detection of potential look-alike/sound-alike medication errors using Veterans Affairs administrative databases. …

  10. Hospital progress in reducing error: the impact of external interventions. | PSNet

    psnet.ahrq.gov/issue/hospital-progress-reducing-error-impact-external-interventions
    December 04, 2016 - Study Hospital progress in reducing error: the impact of external interventions. Citation Text: Hosford SB. Hospital progress in reducing error: the impact of external interventions. Hosp Top. 2008;86(1):9-19. doi:10.3200/HTPS.86.1.9-20. Copy Citation Format: DOI Google S…

  11. SEIPS 101 and seven simple SEIPS tools. | PSNet

    psnet.ahrq.gov/issue/seips-101-and-seven-simple-seips-tools
    October 03, 2013 - Commentary SEIPS 101 and seven simple SEIPS tools. Citation Text: Holden RJ, Carayon P. SEIPS 101 and seven simple SEIPS tools. BMJ Qual Saf. 2021;30(11):901-910. doi:10.1136/bmjqs-2020-012538. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

  12. Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future). | PSNet

    psnet.ahrq.gov/issue/measuring-patient-safety-medicare-patient-safety-monitoring-system-past-present-and-future
    December 18, 2014 - Review Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future). Citation Text: Classen D, Munier W, Verzier N, et al. Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future). J Patient Saf. 2021;17(3)…

  13. The Veterans Affairs shift change physician-to-physician handoff project. | PSNet

    psnet.ahrq.gov/issue/veterans-affairs-shift-change-physician-physician-handoff-project
    April 30, 2014 - Study The Veterans Affairs shift change physician-to-physician handoff project. Citation Text: Anderson J, Shroff D, Curtis A, et al. The Veterans Affairs shift change physician-to-physician handoff project. Jt Comm J Qual Patient Saf. 2010;36(2):62-71. Copy Citation Format: …

  14. Focused ethnography of diagnosis in academic medical centers. | PSNet

    psnet.ahrq.gov/issue/focused-ethnography-diagnosis-academic-medical-centers
    August 14, 2019 - Study Focused ethnography of diagnosis in academic medical centers. Citation Text: Chopra V, Harrod M, Winter S, et al. Focused Ethnography of Diagnosis in Academic Medical Centers. J Hosp Med. 2018;13(10):668-672. doi:10.12788/jhm.2966. Copy Citation Format: DOI Google Sch…

  15. Measuring communication in the surgical ICU: better communication equals better care. | PSNet

    psnet.ahrq.gov/issue/measuring-communication-surgical-icu-better-communication-equals-better-care
    April 03, 2005 - Study Measuring communication in the surgical ICU: better communication equals better care. Citation Text: Williams M, Hevelone N, Alban RF, et al. Measuring communication in the surgical ICU: better communication equals better care. J Am Coll Surg. 2010;210(1):17-22. doi:10.1016/j.jamc…

  16. The effects of bar-coding technology on medication errors: a systematic literature review. | PSNet

    psnet.ahrq.gov/issue/effects-bar-coding-technology-medication-errors-systematic-literature-review
    March 20, 2024 - Review The effects of bar-coding technology on medication errors: a systematic literature review. Citation Text: Hutton K, Ding Q, Wellman G. The Effects of Bar-coding Technology on Medication Errors: A Systematic Literature Review. J Patient Saf. 2021;17(3):e192-e206. doi:10.1097/PTS.00…

  17. The TAKEheart Initiative | Agency for Healthcare Research and Quality

    www.ahrq.gov/takeheart/about/initiative/index.html
    December 01, 2022 - The TAKEheart Initiative Aims AHRQ's TAKEheart initiative seeks to increase participation in cardiac rehabilitation (CR) among eligible patients nationwide. Key Components TAKEheart promotes two proven strategies for increasing referral and enrollment in CR: Implementing automatic referral to make …

  18. Has the pendulum swung too far?; The impact of missed abdominal injuries in the era of nonoperative management. | PSNet

    psnet.ahrq.gov/issue/has-pendulum-swung-too-far-impact-missed-abdominal-injuries-era-nonoperative-management
    August 04, 2021 - Study Has the pendulum swung too far?; The impact of missed abdominal injuries in the era of nonoperative management. Citation Text: Fairfax LM, Christmas B, Deaugustinis M, et al. Has the pendulum swung too far? The impact of missed abdominal injuries in the era of nonoperative manage…

  19. Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy. | PSNet

    psnet.ahrq.gov/issue/understanding-vs-competency-case-accuracy-checking-dispensed-medicines-pharmacy
    December 11, 2013 - Study Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy. Citation Text: James L, Davies G, Kinchin I, et al. Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy. Adv Health Sci Educ Theory Pract. 2010;15(…

  20. Surgical management and outcomes of 165 colonoscopic perforations from a single institution. | PSNet

    psnet.ahrq.gov/issue/surgical-management-and-outcomes-165-colonoscopic-perforations-single-institution
    November 16, 2022 - Study Surgical management and outcomes of 165 colonoscopic perforations from a single institution. Citation Text: Iqbal CW, Cullinane DC, Schiller HJ, et al. Surgical management and outcomes of 165 colonoscopic perforations from a single institution. Arch Surg. 2008;143(7):701-6; discu…
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