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Showing results for "harms".

8301. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50925/psn-pdf
      February 19, 2020 - Report of the Independent Inquiry into the Issues Raised by Paterson. February 19, 2020 James G. House Commons Report 31. Department of Health and Social Care. London, England: Crown Copyright; 2020. ISBN 9781528617284. https://psnet.ahrq.gov/issue/report-independent-inquiry-issues-raised-paterson Shari…

8302. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837744/psn-pdf
      July 27, 2022 - Medication orders with future start dates: how far away is too far? July 27, 2022 ISMP Medication Safety Alert! Acute care edition. July 14, 2022:27(14):1-4. https://psnet.ahrq.gov/issue/medication-orders-future-start-dates-how-far-away-too-far Human errors that occur while interacting with electronic health recor…

8303. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44032/psn-pdf
      April 01, 2015 - ACOG Committee Opinion #621: patient safety and health information technology. April 1, 2015 Improvement C on PS and Q, Management C on P. Committee opinion no. 621: Patient safety and health information technology. Obstet Gynecol. 2015;125(1):282-3. doi:10.1097/01.AOG.0000459867.14114.7a. https://psnet.ahrq.gov/i…

8304. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47051/psn-pdf
      October 18, 2018 - Errors and discrepancies in the administration of intravenous infusions: a mixed methods multihospital observational study. October 18, 2018 Lyons I, Furniss D, Blandford A, et al. Errors and discrepancies in the administration of intravenous infusions: a mixed methods multihospital observational study. BMJ Qual S…

8305. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37151/psn-pdf
      January 02, 2017 - The impact of abbreviations on patient safety. January 2, 2017 Brunetti L, Santell JP, Hicks RW. The impact of abbreviations on patient safety. Jt Comm J Qual Patient Saf. 2007;33(9):576-83. https://psnet.ahrq.gov/issue/impact-abbreviations-patient-safety Avoiding use of unclear or misleading abbreviations is a ke…

8306. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73147/psn-pdf
      April 14, 2021 - Endometriosis affects 1 out of 10 women like me. Yet it often takes a decade to get diagnosed. April 14, 2021 Peikoff L. NBC News. March 31, 2021. https://psnet.ahrq.gov/issue/endometriosis-affects-1-out-10-women-me-yet-it-often-takes-decade-get- diagnosed Patients with endometriosis often experience care de…

8307. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47577/psn-pdf
      January 16, 2019 - Reversing the rise in maternal mortality. January 16, 2019 Kozhimannil KB. Reversing The Rise In Maternal Mortality. Health Aff (Millwood). 2018;37(11):1901-1904. doi:10.1377/hlthaff.2018.1013. https://psnet.ahrq.gov/issue/reversing-rise-maternal-mortality Maternal harm is a sentinel event that is gaining increase…

8308. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838637/psn-pdf
      October 19, 2022 - Patient safety and legal regulations: a total-scale analysis of the scientific literature. October 19, 2022 Yeung AWK, Kletecka-Pulker M, Klager E, et al. Patient safety and legal regulations: a total-scale analysis of the scientific literature. J Patient Saf. 2022;18(7):e1116-e1123. doi:10.1097/pts.000000000000104…

8309. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866411/psn-pdf
      July 31, 2024 - Simulation to Improve Patient Safety: Getting Started. July 31, 2024 Deutsch ES, Bajaj K. Simulation To Improve Patient Safety: Getting Started. Rockville, MD: Agency for Healthcare Research and Quality; July 2024. Publication No. 24-0055. https://psnet.ahrq.gov/issue/simulation-improve-patient-safety-getting-start…

8310. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43178/psn-pdf
      July 28, 2014 - Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety. July 28, 2014 Vincent CA, Burnett S, Carthey J. Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining s…

8311. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43119/psn-pdf
      April 16, 2014 - Still outside the bull's eye: 2014–2015 Targeted Medication Safety Best Practices. April 16, 2014 ISMP Medication Safety Alert! Acute care edition. March 27, 2014;19:1-5. https://psnet.ahrq.gov/issue/still-outside-bulls-eye-2014-2015-targeted-medication-safety-best-practices This newsletter article reports results…

8312. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852805/psn-pdf
      August 23, 2023 - Unstoppable: this doctor has been investigated at every level of government. How is he still practicing? August 23, 2023 Waldman A. ProPublica. August 9, 2023 https://psnet.ahrq.gov/issue/unstoppable-doctor-has-been-investigated-every-level-government-how-he- still-practicing Systemic failures can enable poo…

8313. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45066/psn-pdf
      February 18, 2017 - Improving feedback on junior doctors' prescribing errors: mixed-methods evaluation of a quality improvement project. February 18, 2017 Reynolds M, Jheeta S, Benn J, et al. Improving feedback on junior doctors' prescribing errors: mixed- methods evaluation of a quality improvement project. BMJ Qual Saf. 2017;26(3):…

8314. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45782/psn-pdf
      January 18, 2017 - Standardization of inpatient handoff communication. January 18, 2017 Jewell JA. Standardization of Inpatient Handoff Communication. Pediatrics. 2016;138(5):e20162681. doi:10.1542/peds.2016-2681. https://psnet.ahrq.gov/issue/standardization-inpatient-handoff-communication Handoffs at shift changes are vulnerable to…

8315. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43048/psn-pdf
      April 02, 2014 - Building a Culture of Candour: a Review of the Threshold for the Duty of Candour and of the Incentives for Care Organisations to Be Candid. April 2, 2014 Dalton D, Williams N. London, UK: The Royal College of Surgeons of England; March 2014.  https://psnet.ahrq.gov/issue/building-culture-candour-review-thresh…

8316. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/855436/psn-pdf
      November 15, 2023 - Medication Safety for Look-alike, Sound-alike Medicines. November 15, 2023 Galappatthy P, Mair A, Dhingra-Kumar N et al. Geneva, Switzerland: World Health Organization; 2023. ISBN 9789240058897. https://psnet.ahrq.gov/issue/medication-safety-look-alike-sound-alike-medicines Look-alike, sound-alike (LASA) medicines…

8317. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34755/psn-pdf
      September 06, 2011 - Safe Practices for Better Healthcare: 2006 Update. September 6, 2011 Washington DC: National Quality Forum; 2007. https://psnet.ahrq.gov/issue/safe-practices-better-healthcare-2006-update The National Quality Forum used expert consensus and evidence review to identify 30 health care “safe practices” that should be…

8318. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41952/psn-pdf
      January 16, 2013 - Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system. January 16, 2013 Ford E, Smith K, Harris K, et al. Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system. Med Phys. 2012;39(11):6968-71. doi:…

8319. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61126/psn-pdf
      November 11, 2020 - Potential for false positive results with antigen tests for rapid detection of SARS-CoV-2--letter to clinical laboratory staff and health care providers. November 11, 2020 US Food and Drug Administration: November 3, 2020. https://psnet.ahrq.gov/issue/potential-false-positive-results-antigen-tests-rapid-detection-…

8320. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44918/psn-pdf
      April 13, 2016 - National Reporting and Learning System Research and Development. April 13, 2016 Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research Centre; 2016. https://psnet.ahrq.gov/issue/national-reporting-and-learning-system-research-and-development Incident reporting has a…