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Showing results for "failures".

7601. The elephant of patient safety: what you see depends on how you look. | PSNet
      psnet.ahrq.gov/issue/elephant-patient-safety-what-you-see-depends-how-you-look
      June 22, 2022 - Commentary Classic The elephant of patient safety: what you see depends on how you look. Citation Text: Shojania KG. The elephant of patient safety: what you see depends on how you look. Jt Comm J Qual Patient Saf. 2010;36(9):399-401. Copy Citation Format:…

7602. Potentially inappropriate medication use in hospitalized elders. | PSNet
      psnet.ahrq.gov/issue/potentially-inappropriate-medication-use-hospitalized-elders
      February 17, 2011 - Study Potentially inappropriate medication use in hospitalized elders. Citation Text: Rothberg MB, Pekow PS, Liu F, et al. Potentially inappropriate medication use in hospitalized elders. J Hosp Med. 2008;3(2):91-102. doi:10.1002/jhm.290. Copy Citation Format: DOI Google …

7603. Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement. | PSNet
      psnet.ahrq.gov/issue/use-safety-attitudes-questionnaire-measure-patient-safety-improvement
      August 18, 2010 - Study Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement. Citation Text: Watts B, Percarpio KB, West P, et al. Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement. J Patient Saf. 2010;6(4):206-9. Copy Citation For…

7604. Speaking up about the dangers of the hidden curriculum. | PSNet
      psnet.ahrq.gov/issue/speaking-about-dangers-hidden-curriculum
      September 30, 2020 - Commentary Speaking up about the dangers of the hidden curriculum. Citation Text: Liao JM, Thomas EJ, Bell SK. Speaking up about the dangers of the hidden curriculum. Health Aff (Millwood). 2014;33(1):168-171. doi:10.1377/hlthaff.2013.1073. Copy Citation Format: DOI Google…

7605. Quality improvement and patient safety organizations in anesthesiology. | PSNet
      psnet.ahrq.gov/issue/quality-improvement-and-patient-safety-organizations-anesthesiology
      March 07, 2018 - Commentary Quality improvement and patient safety organizations in anesthesiology. Citation Text: Dutton RP. Quality improvement and patient safety organizations in anesthesiology. AMA J Ethics. 2015;17(3):248-52. doi:10.1001/journalofethics.2015.17.3.pfor1-1503. Copy Citation Form…

7606. Performance measures in neurosurgical patient care: differing applications of patient safety indicators. | PSNet
      psnet.ahrq.gov/issue/performance-measures-neurosurgical-patient-care-differing-applications-patient-safety
      June 03, 2020 - Study Performance measures in neurosurgical patient care: differing applications of patient safety indicators. Citation Text: Moghavem N, McDonald KM, Ratliff JK, et al. Performance Measures in Neurosurgical Patient Care: Differing Applications of Patient Safety Indicators. Med Care. 201…

7607. Learning from mistakes and near mistakes: using root cause analysis as a risk management tool. | PSNet
      psnet.ahrq.gov/issue/learning-mistakes-and-near-mistakes-using-root-cause-analysis-risk-management-tool
      June 19, 2024 - Commentary Learning from mistakes and near mistakes: using root cause analysis as a risk management tool. Citation Text: 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.20…

7608. Physician and nurse well-being, patient safety and recommendations for interventions: cross-sectional survey in hospitals in six European countries. | PSNet
      psnet.ahrq.gov/issue/physician-and-nurse-well-being-patient-safety-and-recommendations-interventions-cross
      September 09, 2020 - Study Physician and nurse well-being, patient safety and recommendations for interventions: cross-sectional survey in hospitals in six European countries. Citation Text: Physician and nurse well-being, patient safety and recommendations for interventions: cross-sectional survey in hospit…

7609. A multiple-drawer medication layout problem in automated dispensing cabinets. | PSNet
      psnet.ahrq.gov/issue/multiple-drawer-medication-layout-problem-automated-dispensing-cabinets
      December 21, 2017 - Study A multiple-drawer medication layout problem in automated dispensing cabinets. Citation Text: Pazour JA, Meller RD. A multiple-drawer medication layout problem in automated dispensing cabinets. Health Care Manag Sci. 2012;15(4). doi:10.1007/s10729-012-9197-8. Copy Citation Fo…

7610. Detection, classification, and correction of defective chemotherapy orders through nursing and pharmacy oversight. | PSNet
      psnet.ahrq.gov/issue/detection-classification-and-correction-defective-chemotherapy-orders-through-nursing-and
      May 27, 2011 - Study Detection, classification, and correction of defective chemotherapy orders through nursing and pharmacy oversight. Citation Text: Mertens WC, Brown DE, Parisi R, et al. Detection, Classification, and Correction of Defective Chemotherapy Orders Through Nursing and Pharmacy Oversig…

7611. Investigating the safety of medication administration in adult critical care settings. | PSNet
      psnet.ahrq.gov/issue/investigating-safety-medication-administration-adult-critical-care-settings
      June 01, 2022 - Review Investigating the safety of medication administration in adult critical care settings. Citation Text: Mansour M, James V, Edgley A. Investigating the safety of medication administration in adult critical care settings. Nurs Crit Care. 2012;17(4):189-97. doi:10.1111/j.1478-5153.2…

7612. Multi-professional patterns and methods of communication during patient handoffs. | PSNet
      psnet.ahrq.gov/issue/multi-professional-patterns-and-methods-communication-during-patient-handoffs
      January 30, 2019 - Study Multi-professional patterns and methods of communication during patient handoffs. Citation Text: Benham-Hutchins MM, Effken JA. Multi-professional patterns and methods of communication during patient handoffs. Int J Med Inform. 2010;79(4):252-67. doi:10.1016/j.ijmedinf.2009.12.00…

7613. Using an objective structured clinical examination to test adherence to Joint Commission National Patient Safety Goal–associated behaviors. | PSNet
      psnet.ahrq.gov/issue/using-objective-structured-clinical-examination-test-adherence-joint-commission-national
      September 26, 2012 - Study Using an objective structured clinical examination to test adherence to Joint Commission National Patient Safety Goal–associated behaviors. Citation Text: Pernar LIM, Shaw T, Pozner CN, et al. Using an Objective Structured Clinical Examination to test adherence to Joint Commissio…

7614. What 'just culture' doesn't understand about just punishment. | PSNet
      psnet.ahrq.gov/issue/what-just-culture-doesnt-understand-about-just-punishment
      December 30, 2014 - Commentary What 'just culture' doesn't understand about just punishment. Citation Text: Reis-Dennis S. What 'Just Culture' doesn't understand about just punishment. J Med Ethics. 2018;44(11):739-742. doi:10.1136/medethics-2018-104911. Copy Citation Format: DOI Google Schola…

7615. A systematic review of falls in hospital for patients with communication disability: highlighting an invisible population. | PSNet
      psnet.ahrq.gov/issue/systematic-review-falls-hospital-patients-communication-disability-highlighting-invisible
      April 15, 2016 - Review A systematic review of falls in hospital for patients with communication disability: highlighting an invisible population. Citation Text: Hemsley B, Steel J, Worrall L, et al. A systematic review of falls in hospital for patients with communication disability: Highlighting an invi…

7616. Implementing human factors in clinical practice. | PSNet
      psnet.ahrq.gov/issue/implementing-human-factors-clinical-practice
      June 28, 2023 - Study Implementing human factors in clinical practice. Citation Text: Timmons S, Baxendale B, Buttery A, et al. Implementing human factors in clinical practice. Emerg Med J. 2015;32(5):368-72. doi:10.1136/emermed-2013-203203. Copy Citation Format: DOI Google Scholar PubMed …

7617. Evaluation of the frequency of dispensing electronically discontinued medications and associated outcomes. | PSNet
      psnet.ahrq.gov/issue/evaluation-frequency-dispensing-electronically-discontinued-medications-and-associated
      March 03, 2019 - Study Evaluation of the frequency of dispensing electronically discontinued medications and associated outcomes. Citation Text: Copi EJ, Kelley LR, Fisher KK. Evaluation of the frequency of dispensing electronically discontinued medications and associated outcomes. J Am Pharm Assoc (2003…

7618. Adverse effects of computers during bedside rounds in a critical care unit. | PSNet
      psnet.ahrq.gov/issue/adverse-effects-computers-during-bedside-rounds-critical-care-unit
      August 02, 2015 - Study Adverse effects of computers during bedside rounds in a critical care unit. Citation Text: Dhillon NK, Francis SE, Tatum JM, et al. Adverse Effects of Computers During Bedside Rounds in a Critical Care Unit. JAMA Surg. 2018;153(11):1052-1053. doi:10.1001/jamasurg.2018.1752. Copy …

7619. Track 9: Emerging Approaches to Drive Change in Healthcare | Digital Healthcare Research
      digital.ahrq.gov/track-9-emerging-approaches-drive-change-healthcare
      January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…

7620. Embracing multiple aims in healthcare improvement and innovation. | PSNet
      psnet.ahrq.gov/issue/embracing-multiple-aims-healthcare-improvement-and-innovation
      June 24, 2020 - Commentary Embracing multiple aims in healthcare improvement and innovation. Citation Text: Amalberti R, Staines A, Vincent CA. Embracing multiple aims in healthcare improvement and innovation. Int J Qual Health Care. 2022;34(1):mzac006. doi:10.1093/intqhc/mzac006. Copy Citation Fo…