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3121. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50615/psn-pdf
      October 30, 2019 - Misidentifying the Unidentified – John Doe and the EHR October 30, 2019 Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr The Case  Two male patients of similar age arrived at the same …

3122. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49667/psn-pdf
      October 01, 2012 - Many of the steps and techniques described above fall under the field of medication safety engineering

3123. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
      February 01, 2017 - PowerPoint Presentation Spotlight The Hazards of Distraction: Ticking All the EHR Boxes * Source and Credits This presentation is based on the February 2017 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Anthony C. Easty, PhD, Adjunct Pr…

3124. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.326_slideshow.ppt
      June 01, 2014 - PowerPoint Presentation Spotlight Wandering Off the Floors: Safety and Security Risks of Patient Wandering 1 This presentation is based on the June 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Thomas A. Smith, CHPA, CPP, President, Healthc…

3125. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
      February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Essay View more articles from the same authors. Ci…

3126. High Reliability Organization (HRO) Principles and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
      February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Conversation View more articles from the same authors. Citation Text: Vogus T, Lee M, Mos…

3127. Hold the tPA | PSNet
      psnet.ahrq.gov/web-mm/hold-tpa
      July 29, 2020 - the Same Author(s) A randomized trial of a multifactorial strategy to prevent serious fall … December 1, 2010 Perspective How Does Infection Prevention

3128. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49427/psn-pdf
      January 01, 2004 - team members to the task at hand and enable them to "speak up" or challenge something that seems to fall … Prevention of similar events may depend on our ability to adopt more effective human-factors-oriented

3129. Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates | PSNet
      psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
      October 30, 2024 - Behavioral health may not fall within traditional funding and reimbursement mechanisms within your facility … July 23, 2024 Patient Safety Innovations Suicide Prevention

3130. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49802/psn-pdf
      August 01, 2017 - addressed through a thorough understanding of the barriers to adherence.(16) Sometimes a process will fall … Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis

3131. Cultural Dimensions of Depression | PSNet
      psnet.ahrq.gov/web-mm/cultural-dimensions-depression
      September 01, 2018 - After the fall of Saigon in 1975, many refugees—estimated at more than 500,000—came to the United States … 2022 Shared understanding of resilient practices in the context of inpatient suicide prevention

3132. Patient Safety in Primary Care | PSNet
      psnet.ahrq.gov/perspective/patient-safety-primary-care
      January 31, 2020 - . [2] Important services delivered by primary care clinicians include health promotion and disease prevention … referrals to ensure they are carried out in a timely way will likely minimize the number of patients who “fall

3133. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50927/psn-pdf
      February 21, 2020 - disease.[2] Important services delivered by primary care clinicians include health promotion and disease prevention … referrals to ensure they are carried out in a timely way will likely minimize the number of patients who “fall

3134. In Conversation With… Ashish K. Jha, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
      May 01, 2013 - measures, it's pretty hard to measure diagnostic errors for example, and some of the other issues that fall … from Medicare's Inpatient Quality Reporting (IQR) program, including process measures focused on the prevention … In 2014, the program will expand to include the prevention of catheter-associated urinary tract infection … The impact of computerized physician order entry on medication error prevention.

3135. Elopement | PSNet
      psnet.ahrq.gov/web-mm/elopement
      July 14, 2010 - These protocols should include assessment and prevention procedures to reduce the risk of harm for patients … Miscarriage June 1, 2003 WebM&M Cases Another Fall

3136. Incidence and causes of critical incidents in emergency departments: a comparison and root cause analysis. | PSNet
      psnet.ahrq.gov/issue/incidence-and-causes-critical-incidents-emergency-departments-comparison-and-root-cause
      January 18, 2023 - January 4, 2012 A randomized trial of a multifactorial strategy to prevent serious fall

3137. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-457
      September 25, 2024 - Fall F, Hu YY, Walker S, et al.

3138. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-349
      July 08, 2022 - commonly reported events, followed by Medication Error, Complication of Procedure/Treatment/Test, and Fall

3139. Improving Patient Safety and Team Communication through Daily Huddles | PSNet
      psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
      September 07, 2019 - Improving Patient Safety and Team Communication through Daily Huddles Citation Text: Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citatio…

3140. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49772/psn-pdf
      October 01, 2016 - Lane-Fall MB, Beidas RS, Pascual JL, et al.