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Showing results for "failures".

  1. Errors in drug computations during newborn intensive care. | PSNet

    psnet.ahrq.gov/issue/errors-drug-computations-during-newborn-intensive-care
    December 15, 2021 - Study Errors in drug computations during newborn intensive care. Citation Text: Perlstein PH, Callison C, White M, et al. Errors in Drug Computations During Newborn Intensive Care. Arch Pediatr Adolesc Med. 1979;133(4):376-379. doi:10.1001/archpedi.1979.02130040030006. Copy Citation …

  2. A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II. | PSNet

    psnet.ahrq.gov/issue/report-card-system-using-error-profile-analysis-and-concurrent-morbidity-and-mortality-review
    June 18, 2008 - Study A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II. Citation Text: Antonacci AC, Lam S, Lavarias V, et al. A report card system using error profile analysis and concurrent morbidity and mortality rev…

  3. Design and implementation of a tool for pharmacists to register potential errors in prescribed medication. | PSNet

    psnet.ahrq.gov/issue/design-and-implementation-tool-pharmacists-register-potential-errors-prescribed-medication
    March 09, 2022 - Study Design and implementation of a tool for pharmacists to register potential errors in prescribed medication. Citation Text: Frid S, Zapico V, Mansilla A, et al. Design and Implementation of a Tool for Pharmacists to Register Potential Errors in Prescribed Medication. Stud Health Tech…

  4. Human error and the problem of causality in analysis of accidents. | PSNet

    psnet.ahrq.gov/issue/human-error-and-problem-causality-analysis-accidents
    August 25, 2021 - Commentary Classic Human error and the problem of causality in analysis of accidents. Citation Text: Rasmussen J. Human error and the problem of causality in analysis of accidents. Philos Trans R Soc Lond B Biol Sci. 1990;327(1241):449-462. Copy Citation …

  5. Promoting patient safety using an early warning scoring system. | PSNet

    psnet.ahrq.gov/issue/promoting-patient-safety-using-early-warning-scoring-system
    October 16, 2012 - Study Promoting patient safety using an early warning scoring system. Citation Text: Higgins Y, Maries-Tillott C, Quinton S, et al. Promoting patient safety using an early warning scoring system. Nurs Stand. 2008;22(44):35-40. Copy Citation Format: Google Scholar PubMed B…

  6. Organizational and safety culture in Canadian intensive care units: relationship to size of intensive care unit and physician management model. | PSNet

    psnet.ahrq.gov/issue/organizational-and-safety-culture-canadian-intensive-care-units-relationship-size-intensive
    November 21, 2016 - Study Organizational and safety culture in Canadian intensive care units: relationship to size of intensive care unit and physician management model. Citation Text: Dodek P, Wong H, Jaswal D, et al. Organizational and safety culture in Canadian intensive care units: relationship to siz…

  7. Evaluating a new rapid response team: NP-led versus intensivist-led comparisons. | PSNet

    psnet.ahrq.gov/issue/evaluating-new-rapid-response-team-np-led-versus-intensivist-led-comparisons
    October 19, 2022 - Study Evaluating a new rapid response team: NP-led versus intensivist-led comparisons. Citation Text: Scherr K, Wilson DM, Wagner J, et al. Evaluating a new rapid response team: NP-led versus intensivist-led comparisons. AACN Adv Crit Care. 2012;23(1):32-42. doi:10.1097/NCI.0b013e31824…

  8. Impact of nighttime rapid response team activation on outcomes of hospitalized patients with acute deterioration. | PSNet

    psnet.ahrq.gov/issue/impact-nighttime-rapid-response-team-activation-outcomes-hospitalized-patients-acute
    April 06, 2022 - Study Impact of nighttime rapid response team activation on outcomes of hospitalized patients with acute deterioration. Citation Text: Fernando SM, Reardon PM, Bagshaw SM, et al. Impact of nighttime Rapid Response Team activation on outcomes of hospitalized patients with acute deteriorat…

  9. Accidents and incidents related to intravenous drug administration: a pre-post study following implementation of smart pumps in a teaching hospital. | PSNet

    psnet.ahrq.gov/issue/accidents-and-incidents-related-intravenous-drug-administration-pre-post-study-following
    September 24, 2016 - Study Accidents and incidents related to intravenous drug administration: a pre-post study following implementation of smart pumps in a teaching hospital. Citation Text: Guérin A, Tourel J, Delage E, et al. Accidents and Incidents Related to Intravenous Drug Administration: A Pre-Post St…

  10. Review of patient safety incidents submitted from critical care units in England & Wales to the UK National Patient Safety Agency. | PSNet

    psnet.ahrq.gov/issue/review-patient-safety-incidents-submitted-critical-care-units-england-wales-uk-national
    July 16, 2008 - Study Review of patient safety incidents submitted from critical care units in England & Wales to the UK National Patient Safety Agency. Citation Text: Thomas AN, Panchagnula U, Taylor RJ. Review of patient safety incidents submitted from Critical Care Units in England & Wales to the U…

  11. Parents' perspectives on navigating the work of speaking up in the NICU. | PSNet

    psnet.ahrq.gov/issue/parents-perspectives-navigating-work-speaking-nicu
    December 04, 2016 - Study Parents' perspectives on navigating the work of speaking up in the NICU. Citation Text: Lyndon A, Wisner K, Holschuh C, et al. Parents' Perspectives on Navigating the Work of Speaking Up in the NICU. J Obstet Gynecol Neonatal Nurs. 2017;46(5):716-726. doi:10.1016/j.jogn.2017.06.009…

  12. Active surveillance of vaccine safety: a system to detect early signs of adverse events. | PSNet

    psnet.ahrq.gov/issue/active-surveillance-vaccine-safety-system-detect-early-signs-adverse-events
    March 29, 2010 - Study Active surveillance of vaccine safety: a system to detect early signs of adverse events. Citation Text: Davis RL, Kolczak M, Lewis E, et al. Active surveillance of vaccine safety: a system to detect early signs of adverse events. Epidemiology. 2005;16(3):336-41. Copy Citation …

  13. Development of a trigger tool to identify adverse events and harm in emergency medical services. | PSNet

    psnet.ahrq.gov/issue/development-trigger-tool-identify-adverse-events-and-harm-emergency-medical-services
    August 07, 2024 - Study Development of a trigger tool to identify adverse events and harm in emergency medical services. Citation Text: Howard IL, Bowen JM, Shaikh LAHA, et al. Development of a trigger tool to identify adverse events and harm in Emergency Medical Services. Emerg Med J. 2017;34(6):391-397.…

  14. Simulation-based assessment identifies longitudinal changes in cognitive skills in an anesthesiology residency training program. | PSNet

    psnet.ahrq.gov/issue/simulation-based-assessment-identifies-longitudinal-changes-cognitive-skills-anesthesiology
    August 11, 2021 - Study Simulation-based assessment identifies longitudinal changes in cognitive skills in an anesthesiology residency training program. Citation Text: Sidi A, Gravenstein N, Vasilopoulos T, et al. Simulation-based assessment identifies longitudinal changes in cognitive skills in an anesth…

  15. What does safety commitment mean to leaders? A multi-method investigation. | PSNet

    psnet.ahrq.gov/issue/what-does-safety-commitment-mean-leaders-multi-method-investigation
    September 11, 2024 - Study What does safety commitment mean to leaders? A multi-method investigation. Citation Text: Fruhen LS, Griffin MA, Andrei DM. What does safety commitment mean to leaders? A multi-method investigation. J Safety Res. 2019;68:203-214. doi:10.1016/j.jsr.2018.12.011. Copy Citation F…

  16. Increasing rate of detection of wrong-patient radiographs: use of photographs obtained at time of radiography. | PSNet

    psnet.ahrq.gov/issue/increasing-rate-detection-wrong-patient-radiographs-use-photographs-obtained-time-radiography
    June 13, 2015 - Study Increasing rate of detection of wrong-patient radiographs: use of photographs obtained at time of radiography. Citation Text: Tridandapani S, Ramamurthy S, Galgano SJ, et al. Increasing Rate of Detection of Wrong-Patient Radiographs: Use of Photographs Obtained at Time of Radiograp…

  17. Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis. | PSNet

    psnet.ahrq.gov/issue/missed-opportunities-initiate-endoscopic-evaluation-colorectal-cancer-diagnosis
    February 15, 2011 - Study Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis. Citation Text: Singh H, Daci K, Petersen L, et al. Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis. Am J Gastroenterol. 2009;104(10):2543-2554. doi:10.103…

  18. The association between sepsis and potential medical injury among hospitalized patients. | PSNet

    psnet.ahrq.gov/issue/association-between-sepsis-and-potential-medical-injury-among-hospitalized-patients
    July 15, 2014 - Study The association between sepsis and potential medical injury among hospitalized patients. Citation Text: Liu V, Turk BJ, Rizk NW, et al. The association between sepsis and potential medical injury among hospitalized patients. Chest. 2012;142(3):606-613. doi:10.1378/chest.11-2556. …

  19. "Sign right here and you're good to go": a content analysis of audiotaped emergency department discharge instructions. | PSNet

    psnet.ahrq.gov/issue/sign-right-here-and-youre-good-go-content-analysis-audiotaped-emergency-department-discharge
    December 18, 2013 - Study "Sign right here and you're good to go": a content analysis of audiotaped emergency department discharge instructions. Citation Text: Vashi A, Rhodes K. "Sign right here and you're good to go": a content analysis of audiotaped emergency department discharge instructions. Ann Emer…

  20. Mortality among patients with acute myocardial infarction: the influences of patient-centered care and evidence-based medicine. | PSNet

    psnet.ahrq.gov/issue/mortality-among-patients-acute-myocardial-infarction-influences-patient-centered-care-and
    April 10, 2024 - Study Mortality among patients with acute myocardial infarction: the influences of patient-centered care and evidence-based medicine. Citation Text: Meterko M, Wright S, Lin H, et al. Mortality among patients with acute myocardial infarction: the influences of patient-centered care and…
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