-
psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - working on his first call night in July at a new hospital, thumbed through the different insulin order forms … This particular hospital used different insulin order forms depending on whether the patient was insulin-dependent … The confused intern chose the wrong form, causing the patient to receive insulin in doses that failed … patient responded quickly to treatment with D50 and had a full recovery once the error in insulin order forms … this critical error in judgment by the new intern, by recognizing the disconnect between the insulin form
-
psnet.ahrq.gov/issue/medication-therapy-management-programs-forming-new-cornerstone-quality-and-safety-medicare
January 06, 2017 - Commentary
Medication therapy management programs: forming a new cornerstone for quality and safety in Medicare.
Citation Text:
Smith SR, Clancy CM. Medication therapy management programs: forming a new cornerstone for quality and safety in medicare. Am J Med Qual. 2006;21(4):276-9.
…
-
psnet.ahrq.gov/issue/what-every-health-care-organization-should-know-about-sentinel-events
November 27, 2018 - The text includes a sample sentinel event root cause analysis form and a glossary.
-
psnet.ahrq.gov/node/33636/psn-pdf
July 01, 2006 - Safety officers need basic training in some form of process improvement methodology, such
as Six Sigma … The Risk Department must share data with the safety officer, as the best form of risk protection is the … working on glycemic control in the intensive care unit,
or a medical director if you were launching a form
-
psnet.ahrq.gov/issue/how-induce-error-management-climate-experimental-evidence-newly-formed-teams
August 24, 2022 - Study
How to induce an error management climate: experimental evidence from newly formed teams.
Citation Text:
Horvath D, Keith N, Klamar A, et al. How to induce an error management climate: experimental evidence from newly formed teams. J Bus Psychol. 2023;38:763–775. doi:10.1007/s10869…
-
psnet.ahrq.gov/issue/context-sensitive-decision-support-infobuttons-electronic-health-records-systematic-review
August 23, 2023 - Infobuttons, a form of clinical decision support, are small icons in the electronic health record that
-
psnet.ahrq.gov/issue/effect-cognitive-debiasing-training-among-family-medicine-residents
August 04, 2021 - Participants were better able to form a plan to mitigate a cognitive bias.
-
psnet.ahrq.gov/issue/implementing-electronic-root-cause-analysis-reporting-system-decrease-hospital-acquired
December 22, 2021 - Dedicated nursing staff were hired and trained, and an electronic health record form was developed to
-
psnet.ahrq.gov/issue/evaluation-intervention-aimed-improving-voluntary-incident-reporting-hospitals
December 16, 2020 - on reportable incidents, changes in the process to reduce the fear of reporting, a shorter reporting form
-
psnet.ahrq.gov/issue/coaching-debriefer-peer-coaching-improve-debriefing-quality-simulation-programs
July 31, 2019 - A core element of the program involves a peer feedback form that explores 10 elements of debriefing
-
psnet.ahrq.gov/issue/business-intelligence-dashboards-patient-safety-and-quality-narrative-literature-review
February 09, 2022 - and SWOT (strengths, weaknesses, opportunities, threats ) of existing patient safety dashboards can form
-
psnet.ahrq.gov/issue/medication-administration-aged-care-facilities-mixed-methods-systematic-review-0
July 31, 2024 - Dose form modification, such as crushing tablets and adding them to food, was a common approach to ensure
-
psnet.ahrq.gov/node/840173/psn-pdf
November 16, 2022 - communicates the result to the case manager or cancer center navigator using a
standardized follow-up request form
-
psnet.ahrq.gov/node/36867/psn-pdf
August 31, 2011 - Using a newly designed form, investigators developed a system of shared ownership among
nurses, pharmacists
-
psnet.ahrq.gov/issue/medication-reconciliation-handbook-2nd-edition
May 04, 2015 - background on the medication reconciliation process and tips for its application, along with sample forms … January 7, 2015
Medication reconciliation physician order form.
-
psnet.ahrq.gov/node/45535/psn-pdf
January 23, 2017 - near-misses
Errors related to the handling of surgical specimens can lead to serious patient harm in the form
-
psnet.ahrq.gov/node/38558/psn-pdf
February 18, 2011 - In this study,
medication discrepancies (among the hospital discharge summary, SNF referral form, and
-
psnet.ahrq.gov/issue/practitioners-agree-medication-reconciliation-value-frustration-and-difficulties-abound
August 09, 2023 - August 31, 2016
Medication reconciliation physician order form.
-
psnet.ahrq.gov/issue/what-medications-does-your-patient-take-enhancing-medication-safety-outpatient-setting
January 08, 2020 - August 31, 2016
Medication reconciliation physician order form.
-
psnet.ahrq.gov/node/41924/psn-pdf
April 05, 2013 - increased the likelihood that a patient would seek legal advice, even though most patients desired some
form