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Showing results for "harms".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72686/psn-pdf
    January 27, 2021 - The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making. January 27, 2021 Croskerry P. New York, NY: Oxford University Press; 2020. ISBN: 9780190088743.  https://psnet.ahrq.gov/issue/cognitive-autopsy-root-cause-analysis-medical-decision-making Diagnostic error reduction methods are evolv…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50600/psn-pdf
    October 30, 2019 - HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. October 30, 2019 HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. Washington DC: US Department of Health and Human Services. October 2019. …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854264/psn-pdf
    October 04, 2023 - Patient death tied to lack of proper escalation process for barcode scanning failures. October 4, 2023 ISMP Medication Safety Alert! Acute Care edition. 2023;28(19):1-3. https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures Lack of experience with distinct process…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50849/psn-pdf
    January 29, 2020 - Prescription drug overload: critics fighting to curb an epidemic of medication side effects. January 29, 2020 Weisman R. Boston Globe. January 13, 2020. https://psnet.ahrq.gov/issue/prescription-drug-overload-critics-fighting-curb-epidemic-medication-side- effects Polypharmacy is a known contributor to adverse dr…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43996/psn-pdf
    November 10, 2018 - When doing wrong feels so right: normalization of deviance. November 10, 2018 Price MR, Williams TC. When Doing Wrong Feels So Right: Normalization of Deviance. J Patient Saf. 2018;14(1):1-2. doi:10.1097/PTS.0000000000000157. https://psnet.ahrq.gov/issue/when-doing-wrong-feels-so-right-normalization-deviance This…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842777/psn-pdf
    January 18, 2023 - Patient safety performance: reversing recent declines through shared profession-wide system-level solutions. January 18, 2023 doi:full/10.1056/CAT.22.0318. https://psnet.ahrq.gov/issue/patient-safety-performance-reversing-recent-declines-through-shared- profession-wide-system The COVID-19 pandemic revealed fractu…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848825/psn-pdf
    May 10, 2023 - Laura Levis' death outside ER has changed hospital signage, lighting in Mass. May 10, 2023 Mullins L, Menard F. WBUR. April 27, 2023. https://psnet.ahrq.gov/issue/laura-levis-death-outside-er-has-changed-hospital-signage-lighting-mass Incomplete information and building design problems can reduce access to care an…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43084/psn-pdf
    May 19, 2014 - How can the criminal law support the provision of quality in healthcare? May 19, 2014 Yeung K, Horder J. How can the criminal law support the provision of quality in healthcare? BMJ Qual Saf. 2014;23(6):519-24. doi:10.1136/bmjqs-2013-002688. https://psnet.ahrq.gov/issue/how-can-criminal-law-support-provision-quali…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45363/psn-pdf
    September 14, 2016 - Effective perioperative communication to enhance patient care. September 14, 2016 Garrett H. Effective Perioperative Communication to Enhance Patient Care. AORN J. 2016;104(2):111-20. doi:10.1016/j.aorn.2016.06.001. https://psnet.ahrq.gov/issue/effective-perioperative-communication-enhance-patient-care Poor team …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45637/psn-pdf
    February 17, 2017 - Opportunities to enhance laboratory professionals' role on the diagnostic team. February 17, 2017 Taylor JR, Thompson PJ, Genzen JR, et al. Opportunities to enhance laboratory professionals' role on the diagnostic team. Lab Med. 2017;48(1):97-103. doi:10.1093/labmed/lmw048. https://psnet.ahrq.gov/issue/opportuniti…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45466/psn-pdf
    September 07, 2016 - Building a highway to quality health care. September 7, 2016 Watson S, Pronovost P. Building a Highway to Quality Health Care. J Patient Saf. 2016;12(3):165-6. doi:10.1097/PTS.0000000000000074. https://psnet.ahrq.gov/issue/building-highway-quality-health-care Substantial progress has been made in improving health …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46748/psn-pdf
    February 08, 2019 - Safety culture, patient safety, and quality of care outcomes: a literature review. February 8, 2019 Lee SE, Scott LD, Dahinten S, et al. Safety Culture, Patient Safety, and Quality of Care Outcomes: A Literature Review. West J Nurs Res. 2019;41(2):279-304. doi:10.1177/0193945917747416. https://psnet.ahrq.gov/issue…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74188/psn-pdf
    December 15, 2021 - Semantically ambiguous language in the teaching operating room. December 15, 2021 Liu C, McKenzie A, Sutkin G. Semantically ambiguous language in the teaching operating room. J Surg Edu. 2021;78(6):1938-1947. doi:10.1016/j.jsurg.2021.03.020. https://psnet.ahrq.gov/issue/semantically-ambiguous-language-teaching-ope…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837430/psn-pdf
    June 15, 2022 - Stop using these adult bed rails, warns the Consumer Product Safety Commission. June 15, 2022 Treisman R. National Public Radio. June 6, 2022 https://psnet.ahrq.gov/issue/stop-using-these-adult-bed-rails-warns-consumer-product-safety-commission Bedrails are used in hospitals and at home to minimize falls despite t…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61106/psn-pdf
    November 04, 2020 - Why false positives merit concern, too. November 4, 2020 Wu KJ. New York Times. October 25, 2020. https://psnet.ahrq.gov/issue/why-false-positives-merit-concern-too False-positive test results, while rare, can create conditions for patient harm. This news story discusses negative impacts of a false-posit…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60218/psn-pdf
    April 08, 2020 - As COVID-19 bears down, doctors confront difficult choices on elective surgeries. April 8, 2020 Alesse L, Dukakis A, Tatum S, Mosk M. ABC News. March 20, 2020. https://psnet.ahrq.gov/issue/covid-19-bears-down-doctors-confront-difficult-choices-elective-surgeries Delays in elective surgery and other procedures have…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47404/psn-pdf
    September 12, 2018 - The gap in electronic drug information resources: a systematic review. September 12, 2018 Rambaran KA, Huynh HA, Zhang Z, et al. The Gap in Electronic Drug Information Resources: A Systematic Review. Cureus. 2018;10(6):e2860. doi:10.7759/cureus.2860. https://psnet.ahrq.gov/issue/gap-electronic-drug-information-res…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44990/psn-pdf
    July 11, 2017 - Automatic errors: a case series on the errors inherent in electronic prescribing. July 11, 2017 Lourenco LM, Bursua A, Groo VL. Automatic Errors: A Case Series on the Errors Inherent in Electronic Prescribing. J Gen Intern Med. 2016;31(7):808-811. doi:10.1007/s11606-016-3606-5. https://psnet.ahrq.gov/issue/automat…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47788/psn-pdf
    March 06, 2019 - Medical device-related pressure ulcers: a systematic review and meta-analysis. March 6, 2019 Jackson D, Sarki AM, Betteridge R, et al. Medical device-related pressure ulcers: A systematic review and meta-analysis. Int J Nurs Stud. 2019;92:109-120. doi:10.1016/j.ijnurstu.2019.02.006. https://psnet.ahrq.gov/issue/me…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44531/psn-pdf
    September 30, 2015 - Never Events for Hospital Care in Canada: Safer Care for Patients. September 30, 2015 Toronto, ON: Health Quality Ontario and the Canadian Patient Safety Institute; September 2015. ISBN: 9781460666180. https://psnet.ahrq.gov/issue/never-events-hospital-care-canada-safer-care-patients The never events list was dev…
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