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Showing results for "harms".

7961. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46958/psn-pdf
      March 28, 2018 - Disposal of paper records containing personal information in hospitals. March 28, 2018 Ramjist JK, Coburn N, Urbach DR, et al. Disposal of Paper Records Containing Personal Information in Hospitals. JAMA. 2018;319(11):1162-1163. doi:10.1001/jama.2017.21533. https://psnet.ahrq.gov/issue/disposal-paper-records-conta…

7962. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48142/psn-pdf
      August 21, 2019 - Six ways to lower errors—and unnecessary surgeries—in radiology exams. August 21, 2019 Panner M. Forbes. August 12, 2019. https://psnet.ahrq.gov/issue/six-ways-lower-errors-and-unnecessary-surgeries-radiology-exams Diagnostic errors can result in harm across the spectrum of practice. Discussing cognitive and syste…

7963. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46192/psn-pdf
      June 07, 2017 - Investigating the causes of adverse events. June 7, 2017 Sanchez JA, Lobdell KW, Moffatt-Bruce SD, et al. Investigating the Causes of Adverse Events. Ann Thorac Surg. 2017;103(6):1693-1699. doi:10.1016/j.athoracsur.2017.04.001. https://psnet.ahrq.gov/issue/investigating-causes-adverse-events Incident analysis enab…

7964. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43552/psn-pdf
      December 16, 2014 - Robotic-assisted surgery: focus on training and credentialing. December 16, 2014 Dubeck D. PA-PSRS Patient Saf Advis. September 2014;11:93-101. https://psnet.ahrq.gov/issue/robotic-assisted-surgery-focus-training-and-credentialing Research has documented a substantial learning curve for surgeons as they develop sk…

7965. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73868/psn-pdf
      September 22, 2021 - Phony diagnoses hide high rates of drugging at nursing homes. September 22, 2021 Thomas K, Gebeloff R, Silver-Greenberg J. New York Times. September 11, 2021. https://psnet.ahrq.gov/issue/phony-diagnoses-hide-high-rates-drugging-nursing-homes Nursing home medication misuse is a contributor to resident harm. T…

7966. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46341/psn-pdf
      August 16, 2017 - In treating sepsis, questions about timing and mandates. August 16, 2017 Abbasi J. In Treating Sepsis, Questions About Timing and Mandates. JAMA. 2017;318(6):506-508. doi:10.1001/jama.2017.7997. https://psnet.ahrq.gov/issue/treating-sepsis-questions-about-timing-and-mandates Delayed treatment of sepsis can result …

7967. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38838/psn-pdf
      May 25, 2010 - Multidisciplinary system for detecting medication errors in antineoplastic chemotherapy. May 25, 2010 Serrano-Fabiá A, Albert-Marí A, Almenar-Cubells D, et al. Multidisciplinary system for detecting medication errors in antineoplastic chemotherapy. J Oncol Pharm Pract. 2010;16(2):105-12. doi:10.1177/10781552093404…

7968. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851195/psn-pdf
      July 05, 2023 - Clinician factors associated with delayed diagnosis of appendicitis. July 5, 2023 Michelson KA, McGarghan FLE, Patterson EE, et al. Clinician factors associated with delayed diagnosis of appendicitis. Diagnosis (Berl). 2023;10(2):183-186. doi:10.1515/dx-2022-0119. https://psnet.ahrq.gov/issue/clinician-factors-ass…

7969. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863223/psn-pdf
      February 28, 2024 - Prioritizing Patient Safety Through Quality Measurement. February 28, 2024 Centers for Medicare & Medicaid Services, March 6 and 21, 2024.  https://psnet.ahrq.gov/issue/prioritizing-patient-safety-through-quality-measurement Quality measurement intersects with patient safety and care improvement efforts to…

7970. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74019/psn-pdf
      July 11, 2023 - PACT Collaborative: Pathway to Accountability, Compassion and Transparency. July 11, 2023 Ariadne Labs, Brigham and Women’s Hospital, Harvard TH Chan School of Public Health. https://psnet.ahrq.gov/issue/pact-collaborative-pathway-accountability-compassion-and-transparency Communication and Resolution Programs (CR…

7971. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43657/psn-pdf
      November 26, 2014 - Strategies for Ensuring the Safe Use of Insulin Pens in the Hospital. November 26, 2014 American Society of Health-System Pharmacists https://psnet.ahrq.gov/issue/strategies-ensuring-safe-use-insulin-pens-hospital Insulin is classified as a high-alert medication due to the potential to cause serious patient harm w…

7972. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837907/psn-pdf
      August 24, 2022 - ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings. August 24, 2022 Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022. https://psnet.ahrq.gov/issue/ismp-guidelines-safe-medication-use-perioperative-and-procedural-settings Medication errors associated with surgery and…

7973. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72715/psn-pdf
      February 03, 2021 - FDA updates vinca alkaloid labeling for preparation in intravenous infusion bags only. February 3, 2021 MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 15, 2021.  https://psnet.ahrq.gov/issue/fda-updates-vinca-alkaloid-labeling-preparation-intravenous-infusion-bags-only Vinc…

7974. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73970/psn-pdf
      October 21, 2021 - The Good, The Bad, and The Ugly: Patient Experiences with CRPs. October 13, 2021 Collaborative for Accountability and Improvement. October 21, 2021.  https://psnet.ahrq.gov/issue/good-bad-and-ugly-patient-experiences-crps Communication-and-resolution program (CRP) initiatives are a valuable strategy for impro…

7975. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39572/psn-pdf
      January 03, 2017 - The tangible handoff: a team approach for advancing structured communication in labor and delivery. January 3, 2017 Block M, Ehrenworth JF, Cuce VM, et al. The tangible handoff: a team approach for advancing structured communication in labor and delivery. Jt Comm J Qual Patient Saf. 2010;36(6):282-287, 241. https:…

7976. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61124/psn-pdf
      November 11, 2020 - Using Twitter to assess patient takes on patient experience. November 11, 2020 Heath S. Patient Engagement HIT. October 29, 2020. https://psnet.ahrq.gov/issue/using-twitter-assess-patient-takes-patient-experience Twitter is evolving as a useful data source for patient safety. This news story discusses an examinati…

7977. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46167/psn-pdf
      June 07, 2017 - Identifying patients with sepsis on the hospital wards. June 7, 2017 Bhattacharjee P, Edelson DP, Churpek MM. Identifying Patients With Sepsis on the Hospital Wards. Chest. 2016;151(4). doi:10.1016/j.chest.2016.06.020. https://psnet.ahrq.gov/issue/identifying-patients-sepsis-hospital-wards Undiagnosed sepsis can l…

7978. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848044/psn-pdf
      April 26, 2023 - Effect of a hospital command centre on patient safety: an interrupted time series study. April 26, 2023 Mebrahtu TF, McInerney CD, Benn J, et al. BMJ Health Care Inform. 2023;30(1):e100653. https://psnet.ahrq.gov/issue/effect-hospital-command-centre-patient-safety-interrupted-time-series-study Command centers…

7979. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72515/psn-pdf
      January 15, 2025 - AHRQ’s Surveys on Patient Safety Culture® Program: An Overview for New Users. December 17, 2024 Rockville, MD: Agency for Healthcare Research and Quality. January 15, 2025. https://psnet.ahrq.gov/issue/tutorial-ahrq-sopsr-data-entry-and-analysis-tool An organization’s understanding of its culture is foundational t…

7980. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50786/psn-pdf
      January 08, 2020 - Patient Safety. January 8, 2020 Halamek LP, ed. Semin Perinatol. 2019;43(8):151172-151182.   https://psnet.ahrq.gov/issue/patient-safety-18 The neonatal intensive care unit (NICU) is a complex environment that serves a vulnerable population at increased risk for harm should errors occur. This special iss…