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2121. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44711/psn-pdf
      September 21, 2016 - The well-defined pediatric ICU: active surveillance using nonmedical personnel to capture less serious safety events. September 21, 2016 White WA, Kennedy K, Belgum HS, et al. The Well-Defined Pediatric ICU: Active Surveillance Using Nonmedical Personnel to Capture Less Serious Safety Events. Jt Comm J Qual Patien…

2122. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47401/psn-pdf
      January 01, 2019 - We want to know: patient comfort speaking up about breakdowns in care and patient experience. October 17, 2018 Fisher K, Smith KM, Gallagher TH, et al. We want to know: patient comfort speaking up about breakdowns in care and patient experience. BMJ Qual Saf. 2019;28(3):190-197. doi:10.1136/bmjqs-2018-008159. http…

2123. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46337/psn-pdf
      August 30, 2017 - Nurses' response to parents' 'speaking-up' efforts to ensure their hospitalized child's safety: an attribution theory perspective. August 30, 2017 Bsharat S, Drach-Zahavy A. Nurses' response to parents' 'speaking-up' efforts to ensure their hospitalized child's safety: an attribution theory perspective. J Adv Nurs…

2124. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36699/psn-pdf
      March 28, 2011 - Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place. March 28, 2011 Olsen S, Neale G, Schwab K, et al. Hospital staff should use more than one method to detect advers…

2125. Failure Mode and Effect Analysis (FMEA) | PSNet
      psnet.ahrq.gov/glossary/failure-mode-and-effect-analysis-fmea
      September 13, 2021 - Failure Mode and Effect Analysis (FMEA) September 13, 2021 Anonymous (not verified) A common process used to prospectively identify error risk within a particular process. FMEA begins with a complete process mapping that identifies all the steps that must occur for a given process to occur (e.g., programming an…

2126. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49685/psn-pdf
      May 01, 2013 - Polypharmacy May 1, 2013 Guglielmo JB. Polypharmacy. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/polypharmacy The Case A 65-year-old man with schizophrenia receives his routine outpatient psychiatric care through an agency. His case manager visits him weekly regarding medication adherence, which include…

2127. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41964/psn-pdf
      April 17, 2013 - Use of HIT for adverse event reporting in nursing homes: barriers and facilitators. April 17, 2013 Wagner LM, Castle NG, Handler S. Use of HIT for adverse event reporting in nursing homes: barriers and facilitators. Geriatr Nurs. 2013;34(2):112-5. doi:10.1016/j.gerinurse.2012.10.003. https://psnet.ahrq.gov/issue/u…

2128. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46342/psn-pdf
      October 04, 2017 - Improving reconciliation following medical injury: a qualitative study of responses to patient safety incidents in New Zealand. October 4, 2017 Moore J, Mello MM. Improving reconciliation following medical injury: a qualitative study of responses to patient safety incidents in New Zealand. BMJ Qual Saf. 2017;26(10…

2129. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39679/psn-pdf
      January 19, 2011 - Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals' psychological well-being. January 19, 2011 Sirriyeh R, Lawton R, Gardner P, et al. Coping with medical error: a systematic review of papers to assess the effects of involveme…

2130. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33701/psn-pdf
      October 01, 2010 - What Makes a Good Checklist October 1, 2010 McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/what-makes-good-checklist Perspective The use of checklists is a primitive yet remarkably effective strategy for ensuring accuracy in complex tasks. Checklists have lo…

2131. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49586/psn-pdf
      May 01, 2009 - Vial Mistakes Involving Heparin May 1, 2009 Vanderveen T. Vial Mistakes Involving Heparin. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin The Case A 65-year-old man was admitted to the hospital for an elective left carotid endarterectomy. During the procedure, the surgeon re…

2132. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49571/psn-pdf
      October 01, 2008 - Coming Up Short October 1, 2008 Hochberg Z'ev. Coming Up Short. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/coming-short The Case A 12-year-old Hispanic female was seen for a well-child check. The child was delivered 2 months prematurely (likely due to domestic violence) in Puerto Rico. She had an intra…

2133. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33610/psn-pdf
      April 01, 2005 - Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet) April 1, 2005 Wachter R. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet). PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet Editorial Five year…

2134. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44084/psn-pdf
      November 03, 2015 - Can staff and patient perspectives on hospital safety predict harm-free care? An analysis of staff and patient survey data and routinely collected outcomes. November 3, 2015 Lawton R, O'Hara JK, Sheard L, et al. Can staff and patient perspectives on hospital safety predict harm- free care? An analysis of staff and…

2135. Afraid to speak up to medical power. | PSNet
      psnet.ahrq.gov/issue/afraid-speak-medical-power
      May 01, 2013 - Newspaper/Magazine Article Afraid to speak up to medical power. Citation Text: Afraid to speak up to medical power. Chen PW. New York Times. February 14, 2013. Copy Citation Save Save to your library Print Download PDF Share Facebook …

2136. Why don't doctors wash their hands more? | PSNet
      psnet.ahrq.gov/issue/why-dont-doctors-wash-their-hands-more
      May 01, 2013 - Newspaper/Magazine Article Why don't doctors wash their hands more? Citation Text: Why don't doctors wash their hands more? Chen PW. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin …

2137. When doctors admit their mistakes. | PSNet
      psnet.ahrq.gov/issue/when-doctors-admit-their-mistakes
      May 01, 2013 - Newspaper/Magazine Article When doctors admit their mistakes. Citation Text: When doctors admit their mistakes. Chen PW. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL…

2138. Do you know what your doctor is talking about? | PSNet
      psnet.ahrq.gov/issue/do-you-know-what-your-doctor-talking-about
      May 01, 2013 - Newspaper/Magazine Article Do you know what your doctor is talking about? Citation Text: Do you know what your doctor is talking about? Chen PW. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter …

2139. Are patients in part to blame when doctors miss the diagnosis? | PSNet
      psnet.ahrq.gov/issue/are-patients-part-blame-when-doctors-miss-diagnosis
      May 01, 2013 - Newspaper/Magazine Article Are patients in part to blame when doctors miss the diagnosis? Citation Text: Are patients in part to blame when doctors miss the diagnosis? Chen PW Copy Citation Save Save to your library Print Download PDF Share …

2140. What drugs do you take? Hospitals seek to collect better data and prevent errors. | PSNet
      psnet.ahrq.gov/issue/what-drugs-do-you-take-hospitals-seek-collect-better-data-and-prevent-errors
      August 17, 2016 - Newspaper/Magazine Article What drugs do you take? Hospitals seek to collect better data and prevent errors. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL June 13, 2011 View more…