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Showing results for "failures".

  1. Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010. | PSNet

    psnet.ahrq.gov/issue/review-patient-safety-incidents-reported-critical-care-units-north-west-england-2009-and-2010
    December 02, 2009 - Study Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010. Citation Text: Thomas AN, Taylor RJ. Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010. Anaesthesia. 2012;67(7):7…

  2. Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. | PSNet

    psnet.ahrq.gov/issue/using-situ-simulation-improve-hospital-cardiopulmonary-resuscitation
    January 02, 2017 - Study Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. Citation Text: Lighthall GK, Poon T, Harrison K. Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. Jt Comm J Qual Patient Saf. 2010;36(5):209-16. Copy Citation Format: …

  3. Reliability of a revised NOTECHS scale for use in surgical teams. | PSNet

    psnet.ahrq.gov/issue/reliability-revised-notechs-scale-use-surgical-teams
    April 11, 2009 - Study Reliability of a revised NOTECHS scale for use in surgical teams. Citation Text: Sevdalis N, Davis R, Koutantji M, et al. Reliability of a revised NOTECHS scale for use in surgical teams. Am J Surg. 2008;196(2):184-90. doi:10.1016/j.amjsurg.2007.08.070. Copy Citation Format…

  4. The contribution of prescription chart design and familiarity to prescribing error: a prospective, randomised, cross-over study. | PSNet

    psnet.ahrq.gov/issue/contribution-prescription-chart-design-and-familiarity-prescribing-error-prospective
    March 20, 2024 - Study The contribution of prescription chart design and familiarity to prescribing error: a prospective, randomised, cross-over study. Citation Text: Tallentire VR, Hale RL, Dewhurst NG, et al. The contribution of prescription chart design and familiarity to prescribing error: a prospe…

  5. Improving anesthesiologists' ability to speak up in the operating room: a randomized controlled experiment of a simulation-based intervention and a qualitative analysis of hurdles and enablers. | PSNet

    psnet.ahrq.gov/issue/improving-anesthesiologists-ability-speak-operating-room-randomized-controlled-experiment
    June 15, 2012 - Study Improving anesthesiologists' ability to speak up in the operating room: a randomized controlled experiment of a simulation-based intervention and a qualitative analysis of hurdles and enablers. Citation Text: Raemer DB, Kolbe M, Minehart RD, et al. Improving Anesthesiologists’ Abil…

  6. Inaccuracy of ECG interpretations reported to the poison center. | PSNet

    psnet.ahrq.gov/issue/inaccuracy-ecg-interpretations-reported-poison-center
    January 20, 2021 - Study Inaccuracy of ECG interpretations reported to the poison center. Citation Text: Prosser JM, Smith SW, Rhim ES, et al. Inaccuracy of ECG interpretations reported to the poison center. Ann Emerg Med. 2011;57(2):122-7. doi:10.1016/j.annemergmed.2010.09.019. Copy Citation Forma…

  7. Survival from in-hospital cardiac arrest during nights and weekends. | PSNet

    psnet.ahrq.gov/issue/survival-hospital-cardiac-arrest-during-nights-and-weekends
    February 18, 2011 - Study Survival from in-hospital cardiac arrest during nights and weekends. Citation Text: Peberdy MA, Ornato JP, Larkin L, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299(7):785-92. doi:10.1001/jama.299.7.785. Copy Citation Format: …

  8. Teamwork in the time of COVID-19. | PSNet

    psnet.ahrq.gov/issue/teamwork-time-covid-19
    November 16, 2022 - Commentary Teamwork in the time of COVID-19. Citation Text: Takizawa PA, Honan L, Brissette D, et al. Teamwork in the time of COVID‐19. FASEB Bioadv. 2020;3(3):175-181. doi:10.1096/fba.2020-00093. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML …

  9. Toward understanding errors in inpatient psychiatry: a qualitative inquiry. | PSNet

    psnet.ahrq.gov/issue/toward-understanding-errors-inpatient-psychiatry-qualitative-inquiry
    December 21, 2018 - Study Toward understanding errors in inpatient psychiatry: a qualitative inquiry. Citation Text: Cullen SW, Nath SB, Marcus SC. Toward understanding errors in inpatient psychiatry: a qualitative inquiry. Psychiatr Q. 2010;81(3):197-205. doi:10.1007/s11126-010-9129-z. Copy Citation …

  10. Pursuing patient safety at the intersection of design, systems engineering, and health care delivery research: an ongoing assessment. | PSNet

    psnet.ahrq.gov/issue/pursuing-patient-safety-intersection-design-systems-engineering-and-health-care-delivery
    June 25, 2018 - Commentary Pursuing patient safety at the intersection of design, systems engineering, and health care delivery research: an ongoing assessment. Citation Text: Henriksen K, Rodrick D, Grace EN, et al. Pursuing Patient Safety at the Intersection of Design, Systems Engineering, and Health …

  11. Effects of fatigue on anaesthetist well-being and patient safety: a narrative review. | PSNet

    psnet.ahrq.gov/issue/effects-fatigue-anaesthetist-well-being-and-patient-safety-narrative-review
    June 28, 2023 - Review Effects of fatigue on anaesthetist well-being and patient safety: a narrative review. Citation Text: Ippolito M, Einav S, Giarratano A, et al. Effects of fatigue on anaesthetist well-being and patient safety: a narrative review. Br J Anaesth. 2024;133(1):111-117. doi:10.1016/j.bja…

  12. An empirically derived taxonomy of factors affecting physicians' willingness to disclose medical errors. | PSNet

    psnet.ahrq.gov/issue/empirically-derived-taxonomy-factors-affecting-physicians-willingness-disclose-medical-errors
    February 15, 2011 - Review An empirically derived taxonomy of factors affecting physicians' willingness to disclose medical errors. Citation Text: Kaldjian LC, Jones EW, Rosenthal GE, et al. An empirically derived taxonomy of factors affecting physicians’ willingness to disclose medical errors. J Gen Inter…

  13. A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain. | PSNet

    psnet.ahrq.gov/issue/diagnostic-time-out-improve-differential-diagnosis-pediatric-abdominal-pain
    February 10, 2021 - Study A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain. Citation Text: Kasick RT, Melvin JE, Perera ST, et al. A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain. Diagnosis (Berl). 2021;8(2):209-217. doi:10.1515/dx-2019-…

  14. Prevalence and predictability of low-yield inpatient laboratory diagnostic tests. | PSNet

    psnet.ahrq.gov/issue/prevalence-and-predictability-low-yield-inpatient-laboratory-diagnostic-tests
    November 13, 2024 - Journal Article Prevalence and predictability of low-yield inpatient laboratory diagnostic tests. Citation Text: Xu S, Hom J, Balasubramanian S, et al. Prevalence and Predictability of Low-Yield Inpatient Laboratory Diagnostic Tests. JAMA Netw Open. 2019;2(9):e1910967. doi:10.1001/jamane…

  15. The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives. | PSNet

    psnet.ahrq.gov/issue/henry-ford-health-system-no-harm-campaign-comprehensive-model-reduce-harm-and-save-lives
    May 11, 2019 - Commentary The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives. Citation Text: Conway WA, Hawkins S, Jordan J, et al. 2011 John M. Eisenberg Patient Safety and Quality Awards. The Henry Ford Health System No Harm Campaign: a comprehensive mo…

  16. Safe practices for copy and paste in the EHR. Systematic review, recommendations, and novel model for health IT collaboration. | PSNet

    psnet.ahrq.gov/issue/safe-practices-copy-and-paste-ehr-systematic-review-recommendations-and-novel-model-health-it
    April 08, 2018 - Review Safe practices for copy and paste in the EHR. Systematic review, recommendations, and novel model for health IT collaboration. Citation Text: Tsou AY, Lehmann CU, Michel J, et al. Safe Practices for Copy and Paste in the EHR. Systematic Review, Recommendations, and Novel Model for…

  17. Who is in charge of patient safety? Work practice, work processes and utopian views of automatic drug dispensing systems. | PSNet

    psnet.ahrq.gov/issue/who-charge-patient-safety-work-practice-work-processes-and-utopian-views-automatic-drug
    September 14, 2016 - Commentary Who is in charge of patient safety? Work practice, work processes and utopian views of automatic drug dispensing systems. Citation Text: Balka E, Kahnamoui N, Nutland K. Who is in charge of patient safety? Work practice, work processes and utopian views of automatic drug dis…

  18. Characteristics and trends of medical diagnostic errors in the United States. | PSNet

    psnet.ahrq.gov/issue/characteristics-and-trends-medical-diagnostic-errors-united-states
    December 14, 2022 - Study Characteristics and trends of medical diagnostic errors in the United States. Citation Text: Ao HS, Matthews T. Characteristics and trends of medical diagnostic errors in the United States. Patient Safety. 2024;6(1):123603. doi:10.33940/001c.123603. Copy Citation Format: …

  19. Medication errors and error chains involving high-alert medications in a paediatric hospital setting: a qualitative analysis of self-reported medication safety incidents. | PSNet

    psnet.ahrq.gov/issue/medication-errors-and-error-chains-involving-high-alert-medications-paediatric-hospital
    March 27, 2024 - Study Medication errors and error chains involving high-alert medications in a paediatric hospital setting: a qualitative analysis of self-reported medication safety incidents. Citation Text: Kuitunen S, Saksa M, Holmström A-R. Medication errors and error chains involving high-alert medi…

  20. Designing an abstraction instrument: lessons from efforts to validate the AHRQ Patient Safety Indicators. | PSNet

    psnet.ahrq.gov/issue/designing-abstraction-instrument-lessons-efforts-validate-ahrq-patient-safety-indicators
    January 13, 2010 - Commentary Designing an abstraction instrument: lessons from efforts to validate the AHRQ Patient Safety Indicators. Citation Text: Utter GH, Borzecki A, Rosen AK, et al. Designing an abstraction instrument: lessons from efforts to validate the AHRQ patient safety indicators. Jt Comm J Q…
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