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Showing results for "harms".

8461. 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:…

8462. 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-…

8463. 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…

8464. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867021/psn-pdf
      October 23, 2024 - Blind Spots: When Medicine Gets It Wrong, and What It Means for Our Health. October 23, 2024 Makary M. Blind Spots: When Medicine Gets It Wrong, And What It Means For Our Health. New York, NY: Bloomsbury Publishing; 2024. ISBN 9781639735310. https://psnet.ahrq.gov/issue/blind-spots-when-medicine-gets-it-wrong-and-…

8465. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45530/psn-pdf
      October 19, 2016 - As a critical behavior to improve quality and patient safety in health care: speaking up! October 19, 2016 Nacioglu A. As a critical behavior to improve quality and patient safety in health care: speaking up!. Safety in Health. 2016;2(1). doi:10.1186/s40886-016-0021-x. https://psnet.ahrq.gov/issue/critical-behavio…

8466. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50428/psn-pdf
      September 04, 2019 - Patient safety incidents caused by poor quality surgical instruments. September 4, 2019 Dominguez ED, Rocos B. Patient Safety Incidents Caused by Poor Quality Surgical Instruments. Cureus. 2019;11(6):e4877. doi:10.7759/cureus.4877. https://psnet.ahrq.gov/issue/patient-safety-incidents-caused-poor-quality-surgical-…

8467. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837300/psn-pdf
      June 01, 2022 - Surgery is in itself a risk factor for the patient. June 1, 2022 Aranaz-Ostáriz V, Gea-Velázquez De Castro MT, López-Rodríguez-Arias F, et al. Surgery is in itself a risk factor for the patient. Int J Environ Res Public Health. 2022;19(8):4761. doi:10.3390/ijerph19084761. https://psnet.ahrq.gov/issue/surgery-itself…

8468. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74015/psn-pdf
      October 27, 2021 - Safer Services: A Toolkit for Specialist Mental Health Services and Primary Care. October 27, 2021 National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of Manchester; May 31, 2021 https://psnet.ahrq.gov/issue/safer-services-toolkit-specialist-mental-health-services-and…

8469. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47959/psn-pdf
      May 15, 2019 - A quality improvement initiative to reduce safety events among adolescents hospitalized after a suicide attempt. May 15, 2019 Noelck M, Velazquez-Campbell M, Austin JP. A Quality Improvement Initiative to Reduce Safety Events Among Adolescents Hospitalized After a Suicide Attempt. Hosp Pediatr. 2019;9(5):365-372. …

8470. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60914/psn-pdf
      September 16, 2020 - Opioid stewardship program and postoperative adverse events: a difference-in-differences cohort study. September 16, 2020 Barreveld AM, McCarthy RJ, Elkassabany N, et al. Opioid stewardship program and postoperative adverse events: a difference-in-differences cohort study. Anesthesiology. 2020;132(6):1558-1568. do…

8471. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72582/psn-pdf
      December 16, 2020 - Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died. December 16, 2020 Washington, DC: Department of Veterans Affairs, Office of Inspector General; November 17, 2020. Report No 19-08542-11. https://psnet.ahrq.gov/issue/deficiencies-veterans-crisis-line-response-veteran-caller-who-died I…

8472. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/862153/psn-pdf
      February 07, 2024 - Anticipating patient safety events in psychiatric care. February 7, 2024 Yerstein MC, SUNDARARAJ DEEPIKA, McClean M, et al. Anticipating patient safety events in psychiatric care. J Psychiatr Pract. 2024;30(1):68-72. doi:10.1097/pra.0000000000000760. https://psnet.ahrq.gov/issue/anticipating-patient-safety-events-p…

8473. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73500/psn-pdf
      July 14, 2021 - 'An ongoing nightmare': people with obesity face major obstacles when seeking medical care. July 14, 2021 Schapiro R. NBC News. June 27, 2021. https://psnet.ahrq.gov/issue/ongoing-nightmare-people-obesity-face-major-obstacles-when-seeking- medical-care System failures cause care delays in a wide range of pat…

8474. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47843/psn-pdf
      March 06, 2019 - Structural iatrogenesis—a 43-year-old man with "opioid misuse." March 6, 2019 Stonington S, Coffa D. Structural Iatrogenesis - A 43-Year-Old Man with "Opioid Misuse". N Engl J Med. 2019;380(8):701-704. doi:10.1056/NEJMp1811473. https://psnet.ahrq.gov/issue/structural-iatrogenesis-43-year-old-man-opioid-misuse The…

8475. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45409/psn-pdf
      May 17, 2021 - ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings. May 17, 2021 Horsham, PA: Institute of Safe Medication Practices; 2021 https://psnet.ahrq.gov/issue/ismp-list-high-alert-medications-long-term-care-ltc-settings Long-term care patients often have concurrent conditions that increase their risk of…

8476. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47165/psn-pdf
      June 13, 2018 - Changing how we think about healthcare improvement. June 13, 2018 Braithwaite J. Changing how we think about healthcare improvement. BMJ. 2018;361:k2014. doi:10.1136/bmj.k2014. https://psnet.ahrq.gov/issue/changing-how-we-think-about-healthcare-improvement In learning organizations, leadership behavior creates a s…

8477. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43647/psn-pdf
      November 12, 2014 - Mid Staffordshire NHS Foundation Trust Quality Report. November 12, 2014 Newcastle Upon Tyne, UK: Care Quality Commission; October 9, 2014. https://psnet.ahrq.gov/issue/mid-staffordshire-nhs-foundation-trust-quality-report The Mid Staffordshire Trust has been under much scrutiny in recent years. This report highlig…

8478. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43639/psn-pdf
      October 29, 2014 - Ebola case raises concern about everyday hospital safety. October 29, 2014 Rodricks D. Baltimore Sun. October 14, 2014. https://psnet.ahrq.gov/issue/ebola-case-raises-concern-about-everyday-hospital-safety Although significant progress has been made in improving patient safety over the past decade, many medical e…

8479. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852278/psn-pdf
      August 09, 2023 - Identifying failure modes in telemedicine: an instructional needs assessment. August 9, 2023 Monkman H, Kuziemsky C, Homco J, et al. Identifying failure modes in telemedicine: an instructional needs assessment. Stud Health Technol Inform. 2023;304:39-43. doi:10.3233/shti230365. https://psnet.ahrq.gov/issue/identif…

8480. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74176/psn-pdf
      December 15, 2021 - Reducing medication errors for adults in hospital settings. December 15, 2021 Ciapponi A, Fernandez Nievas SE, Seijo M, et al. Reducing medication errors for adults in hospital settings. Cochrane Database Syst Rev. 2021;11(11):CD009985. doi:10.1002/14651858.cd009985.pub2. https://psnet.ahrq.gov/issue/reducing-medi…