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Showing results for "failures".

  1. Dynamic pocket card for implementing ISBAR in shift handover communication. | PSNet

    psnet.ahrq.gov/issue/dynamic-pocket-card-implementing-isbar-shift-handover-communication
    July 10, 2024 - Study Dynamic pocket card for implementing ISBAR in shift handover communication. Citation Text: Schmidt T, Kocher DR, Mahendran P, et al. Dynamic Pocket Card for Implementing ISBAR in Shift Handover Communication. Stud Health Technol Inform. 2019;267:224-229. doi:10.3233/SHTI190831. …

  2. Impact of a relocation to a new critical care building on pediatric safety events. | PSNet

    psnet.ahrq.gov/issue/impact-relocation-new-critical-care-building-pediatric-safety-events
    May 27, 2020 - Study Impact of a relocation to a new critical care building on pediatric safety events. Citation Text: Furthmiller A, Sahay R, Zhang B, et al. Impact of a relocation to a new critical care building on pediatric safety events. J Hosp Med. 2024;19(5):589-595. doi:10.1002/jhm.13324. Copy…

  3. Relationship of staff information sharing and advice networks to patient safety outcomes. | PSNet

    psnet.ahrq.gov/issue/relationship-staff-information-sharing-and-advice-networks-patient-safety-outcomes
    June 22, 2011 - Study Relationship of staff information sharing and advice networks to patient safety outcomes. Citation Text: Brewer BB, Carley KM, Benham-Hutchins MM, et al. Relationship of Staff Information Sharing and Advice Networks to Patient Safety Outcomes. J Nurs Adm. 2018;48(9):437-444. doi:10…

  4. A review of incidents related to health information technology in Swedish healthcare to characterise system issues as a basis for improvement in clinical practice. | PSNet

    psnet.ahrq.gov/issue/review-incidents-related-health-information-technology-swedish-healthcare-characterise-system
    December 20, 2023 - Study A review of incidents related to health information technology in Swedish healthcare to characterise system issues as a basis for improvement in clinical practice. Citation Text: Pan D, Nilsson E, Rahman Jabin MS. A review of incidents related to health information technology in Sw…

  5. Drug-related morbidity and mortality and the economic impact of pharmaceutical care. | PSNet

    psnet.ahrq.gov/issue/drug-related-morbidity-and-mortality-and-economic-impact-pharmaceutical-care
    December 23, 2008 - Study Drug-related morbidity and mortality and the economic impact of pharmaceutical care. Citation Text: Johnson JA, Bootman JL. Drug-related morbidity and mortality and the economic impact of pharmaceutical care. Am J Health Syst Pharm. 1997;54(5):554-8. Copy Citation Format: …

  6. Reducing cardiopulmonary arrest rates in a three-year regional rapid response system collaborative. | PSNet

    psnet.ahrq.gov/issue/reducing-cardiopulmonary-arrest-rates-three-year-regional-rapid-response-system-collaborative
    March 04, 2011 - Study Reducing cardiopulmonary arrest rates in a three-year regional rapid response system collaborative. Citation Text: Rosen MJ, Hoberman AJ, Ruiz RE, et al. Reducing cardiopulmonary arrest rates in a three-year regional rapid response system collaborative. Jt Comm J Qual Patient Saf…

  7. Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care. | PSNet

    psnet.ahrq.gov/issue/prevalence-triggers-and-patient-harm-identified-global-trigger-tool-specialized-palliative
    June 14, 2023 - Study Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care. Citation Text: Fredheim OMS, Klingenberg E, Lindahl AK. Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care. J Palliat Med.…

  8. Documenting quality improvement and patient safety efforts: the quality portfolio. A statement from the Academic Hospitalist Taskforce. | PSNet

    psnet.ahrq.gov/issue/documenting-quality-improvement-and-patient-safety-efforts-quality-portfolio-statement
    January 13, 2021 - Commentary Documenting quality improvement and patient safety efforts: the quality portfolio. A statement from the Academic Hospitalist Taskforce. Citation Text: Taylor BB, Parekh V, Estrada CA, et al. Documenting quality improvement and patient safety efforts: the quality portfolio. A…

  9. Overlapping surgery in orthopaedics: a review of efficacy, surgical costs, surgical outcomes, and patient safety. | PSNet

    psnet.ahrq.gov/issue/overlapping-surgery-orthopaedics-review-efficacy-surgical-costs-surgical-outcomes-and-patient
    November 03, 2021 - Review Overlapping surgery in orthopaedics: a review of efficacy, surgical costs, surgical outcomes, and patient safety. Citation Text: Ahmed M, Suhrawardy A, Olszewski A, et al. Overlapping surgery in orthopaedics: a review of efficacy, surgical costs, surgical outcomes, and patient saf…

  10. Pharmacologically inappropriate prescriptions for elderly patients in general practice: how common? | PSNet

    psnet.ahrq.gov/issue/pharmacologically-inappropriate-prescriptions-elderly-patients-general-practice-how-common
    March 08, 2023 - Study Pharmacologically inappropriate prescriptions for elderly patients in general practice: how common? Citation Text: Brekke M, Rognstad S, Straand J, et al. Pharmacologically inappropriate prescriptions for elderly patients in general practice: How common? Baseline data from The Pr…

  11. Unanticipated death after discharge home from the emergency department. | PSNet

    psnet.ahrq.gov/issue/unanticipated-death-after-discharge-home-emergency-department
    November 16, 2022 - Study Unanticipated death after discharge home from the emergency department. Citation Text: Sklar DP, Crandall CS, Loeliger E, et al. Unanticipated Death After Discharge Home From the Emergency Department. Ann Emerg Med. 2007;49(6). doi:10.1016/j.annemergmed.2006.11.018. Copy Citati…

  12. Getting it right for patient safety: specimen collection process improvement from operating room to pathology. | PSNet

    psnet.ahrq.gov/issue/getting-it-right-patient-safety-specimen-collection-process-improvement-operating-room
    July 16, 2013 - Commentary Getting it right for patient safety: specimen collection process improvement from operating room to pathology. Citation Text: D'Angelo R, Mejabi O. Getting It Right for Patient Safety:  Specimen Collection Process Improvement From Operating Room to Pathology. Am J Clin Pathol.…

  13. Pediatric medication safety considerations for pharmacists in an adult hospital setting. | PSNet

    psnet.ahrq.gov/issue/pediatric-medication-safety-considerations-pharmacists-adult-hospital-setting
    January 29, 2020 - Commentary Pediatric medication safety considerations for pharmacists in an adult hospital setting. Citation Text: Kennedy AR, Massey LR. Pediatric medication safety considerations for pharmacists in an adult hospital setting. Am J Health Syst Pharm. 2019;76(19):1481-1491. doi:10.1093/aj…

  14. ASPEN survey of parenteral nutrition access issues: how the system fails the patients. | PSNet

    psnet.ahrq.gov/issue/aspen-survey-parenteral-nutrition-access-issues-how-system-fails-patients
    October 02, 2013 - Study ASPEN survey of parenteral nutrition access issues: how the system fails the patients. Citation Text: Mirtallo JM, Allen P, Book WM, et al. ASPEN survey of parenteral nutrition access issues: how the system fails the patient. Nutr Clin Pract. 2024;39(5):1164-1181. doi:10.1002/ncp.1…

  15. Racial/ethnic disparities in interhospital transfer for conditions with a mortality benefit to transfer among patients with Medicare. | PSNet

    psnet.ahrq.gov/issue/racialethnic-disparities-interhospital-transfer-conditions-mortality-benefit-transfer-among
    April 14, 2021 - Study Racial/ethnic disparities in interhospital transfer for conditions with a mortality benefit to transfer among patients with Medicare. Citation Text: Racial/ethnic disparities in interhospital transfer for conditions with a mortality benefit to transfer among patients with Medicare.…

  16. Systematic video game training in surgical novices improves performance in virtual reality endoscopic surgical simulators: a prospective randomized study. | PSNet

    psnet.ahrq.gov/issue/systematic-video-game-training-surgical-novices-improves-performance-virtual-reality
    January 18, 2011 - Study Systematic video game training in surgical novices improves performance in virtual reality endoscopic surgical simulators: a prospective randomized study. Citation Text: Schlickum MK, Hedman L, Enochsson L, et al. Systematic video game training in surgical novices improves perfor…

  17. Competition and health plan performance: evidence from health maintenance organization insurance markets. | PSNet

    psnet.ahrq.gov/issue/competition-and-health-plan-performance-evidence-health-maintenance-organization-insurance
    July 14, 2009 - Study Competition and health plan performance: evidence from health maintenance organization insurance markets. Citation Text: Scanlon D, Swaminathan S, Chernew M, et al. Competition and health plan performance: evidence from health maintenance organization insurance markets. Med Care.…

  18. Residents' numeric inputting error in computerized physician order entry prescription. | PSNet

    psnet.ahrq.gov/issue/residents-numeric-inputting-error-computerized-physician-order-entry-prescription
    March 24, 2019 - Study Residents' numeric inputting error in computerized physician order entry prescription. Citation Text: Wu X, Wu C, Zhang K, et al. Residents' numeric inputting error in computerized physician order entry prescription. Int J Med Inform. 2016;88:25-33. doi:10.1016/j.ijmedinf.2016.01.0…

  19. Handoff tool improves transitions from the operating room to the neonatal intensive care unit. | PSNet

    psnet.ahrq.gov/issue/handoff-tool-improves-transitions-operating-room-neonatal-intensive-care-unit
    November 16, 2022 - Study Handoff tool improves transitions from the operating room to the neonatal intensive care unit. Citation Text: Gallois JB, Zagory JA, Barkemeyer B, et al. Handoff tool improves transitions from the operating room to the neonatal intensive care unit. Pediatr Qual Saf. 2023;8(5):e695.…

  20. IT-CARES: an interactive tool for case-crossover analyses of electronic medical records for patient safety. | PSNet

    psnet.ahrq.gov/issue/it-cares-interactive-tool-case-crossover-analyses-electronic-medical-records-patient-safety
    October 30, 2013 - Study IT-CARES: an interactive tool for case-crossover analyses of electronic medical records for patient safety. Citation Text: Caron A, Chazard E, Muller J, et al. IT-CARES: an interactive tool for case-crossover analyses of electronic medical records for patient safety. J Am Med Infor…
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