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Showing results for "harms".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838192/psn-pdf
    September 28, 2022 - When medical error becomes personal, activism becomes painful. September 28, 2022 Millenson M. Forbes. September 16, 2022. https://psnet.ahrq.gov/issue/when-medical-error-becomes-personal-activism-becomes-painful Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm w…

  2. A Path Forward for Diagnostic Safety Improvement Leadership | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-5.html
    June 01, 2021 - Leadership To Improve Diagnosis: A Call to Action A Path Forward for Diagnostic Safety Improvement Leadership Previous Page Next Page Table of Contents Leadership To Improve Diagnosis: A Call to Action Diagnostic Safety as a Challenge for Healthcare Leadership Why Are Leaders Essential to Diagno…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839327/psn-pdf
    December 05, 2024 - The National Healthcare System Action Alliance for Patient and Workforce Safety. December 5, 2024 US Department of Health and Human Services. https://psnet.ahrq.gov/issue/national-healthcare-system-action-alliance-advance-patient-safety The large system change required to reduce patient harm requires multi-stakeho…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74846/psn-pdf
    February 16, 2022 - Weight-based Medication Errors in Children. February 16, 2022 Farnborough, UK: Healthcare Safety Investigation Branch; February 2022. https://psnet.ahrq.gov/issue/weight-based-medication-errors-children Weight-calculation errors can result in pediatric patient harm as they affect medication prescribing, dispensing…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44291/psn-pdf
    September 13, 2016 - A piece of my mind. I'm sorry. September 13, 2016 Kahn JS. A PIECE OF MY MIND. I'm Sorry. JAMA. 2015;313(24):2427-8. doi:10.1001/jama.2014.6507. https://psnet.ahrq.gov/issue/piece-my-mind-im-sorry Being accountable for errors and working to learn from them is key to improving patient safety. This commentary descri…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837703/psn-pdf
    July 20, 2022 - Family safety reporting in hospitalized children with medical complexity. July 20, 2022 Mercer AN, Mauskar S, Baird JD, et al. Family safety reporting in hospitalized children with medical complexity. Pediatrics. 2022;150(2):e2021055098. doi:10.1542/peds.2021-055098. https://psnet.ahrq.gov/issue/family-safety-repo…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848827/psn-pdf
    May 10, 2023 - TQIP Mortality Reporting System Case Reports. May 10, 2023 ACS TQIP Mortality Reporting System Writing Group. J Trauma Acute Care Surg. 2023. https://psnet.ahrq.gov/issue/tqip-mortality-reporting-system-case-reports Anonymous case reporting provides opportunities to examine unexpected patient harm instances to pin…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838031/psn-pdf
    September 13, 2022 - Addressing the Loss of Trust in Safety Culture. September 7, 2022 Philadelphia, PA: Building Trust and the ABIM Foundation; September 13, 2022.  https://psnet.ahrq.gov/issue/addressing-loss-trust-safety-culture Trust in patient safety processes encourages reporting of concerns, learning from error, and develop…

  9. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-version-2-resource-list.pdf
    December 01, 2024 - strategies that hospitals and clinical teams can use to ensure that people understand the benefits, harms

  10. The Role of Undergraduate Nursing Education in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
    November 27, 2023 - They clearly don’t understand the potential risks and harms that could happen based on their care.

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49851/psn-pdf
    January 01, 2019 - One Bronchoscopy, Two Errors January 1, 2019 Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors The Case A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic respiratory failure…

  12. Primers | PSNet

    psnet.ahrq.gov/primers-0
    March 15, 2025 - Primers Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts. Latest Primers Clinical Decision Support Systems March…

  13. The Magnetic Deflection | PSNet

    psnet.ahrq.gov/web-mm/magnetic-deflection
    November 18, 2016 - The Magnetic Deflection Citation Text: Kanal E. The Magnetic Deflection. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…

  14. Patient Safety and the Evolution of WebM&M and PSNet | PSNet

    psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet
    April 01, 2008 - Patient Safety and the Evolution of WebM&M and PSNet September 1, 2019  View more articles from the same authors. Citation Text: Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. Rockville (MD): Agency for Healthcare Resea…

  15. 102-How-Integrate-Cusp-Approach-Guide (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/102-how-integrate-cusp-approach-guide.docx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention How To Integrate a CUSP Approach ICU & Non-ICU Slide Title and Commentary Slide Number and Slide How to Integrate a CUSP Approach SAY: Welcome to this presentation about the Comprehensive Unit-based Safety Program, or CUSP. This presentation discusses how to integrate a CUSP…

  16. 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 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL February 9, 2021 …

  17. Making Healthcare Safer IV: Interventions to Prevent Nonventilator Hospital-acquired Pneumonia (NV-HAP) for Inpatients | Effective Health Care (EHC) Program

    effectivehealthcare.ahrq.gov/products/nv-hap/protocol

  18. Identifying Safety Events in the Prehospital Setting | PSNet

    psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
    May 16, 2022 - data emerging on prevalence of specific safety events within the prehospital setting or associated harms

  19. Closing the Feedback Loop to Improve Diagnostic Quality - 2010 | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/closing-feedback-loop-improve-diagnostic-quality/annual-summary/2010
    January 01, 2010 - Closing the Feedback Loop to Improve Diagnostic Quality - 2010 Project Name Closing the Feedback Loop to Improve Diagnostic Quality Principal Investigator Weiss, Eta Organization University of Alabama at Birmingham Funding Mechanism RFA: HS07-002: Ambulatory Safety …

  20. Do medical inpatients who report poor service quality experience more adverse events and medical errors? | PSNet

    psnet.ahrq.gov/issue/do-medical-inpatients-who-report-poor-service-quality-experience-more-adverse-events-and
    July 14, 2021 - Study Classic Do medical inpatients who report poor service quality experience more adverse events and medical errors? Citation Text: Taylor BB, Marcantonio ER, Pagovich O, et al. Do medical inpatients who report poor service quality experience more adverse ev…
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