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Showing results for "harms".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60359/psn-pdf
    May 20, 2020 - Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. May 20, 2020 ISMP Medication Safety Alert! Acute care edition. May 7, 2020;25(9). https://psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone- overdose Lack of familiarity with sm…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853978/psn-pdf
    September 27, 2023 - Fragmented: A Doctor's Quest to Piece Together American Health Care. September 27, 2023 Yurkiewicz I. New York, NY: WW Norton & Company, Inc; 2023. ISBN: 9780393881196. https://psnet.ahrq.gov/issue/doctors-quest-piece-together-american-health-care Disjointed health care processes contribute to missed test resu…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837895/psn-pdf
    August 24, 2022 - Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia. August 24, 2022 Keil O, Brunsmann K, Boethig D, et al. Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia. Paediatr Anaesth. 2022;32(10):1144-1150. doi:10.1111/pan.14535.…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837894/psn-pdf
    August 24, 2022 - Identifying boundary spanning reporter roles in patient safety events. August 24, 2022 Hurley VB, Boxley C, Sloss EA, et al. Identifying boundary spanning reporter roles in patient safety events. J Patient Saf Risk Manag. 2022;27(4):181-187. doi:10.1177/25160435221103096. https://psnet.ahrq.gov/issue/identifying-b…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47423/psn-pdf
    January 27, 2019 - A health system–wide initiative to decrease opioid-related morbidity and mortality. January 27, 2019 Weiner SG, Price CN, Atalay AJ, et al. A Health System-Wide Initiative to Decrease Opioid-Related Morbidity and Mortality. Jt Comm J Qual Patient Saf. 2019;45(1):3-13. doi:10.1016/j.jcjq.2018.07.003. https://psnet.…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47713/psn-pdf
    June 14, 2019 - Medication appropriateness in vulnerable older adults: healthy skepticism of appropriate polypharmacy. June 14, 2019 Fried TR, Mecca MC. Medication Appropriateness in Vulnerable Older Adults: Healthy Skepticism of Appropriate Polypharmacy. J Am Geriatr Soc. 2019;67(6):1123-1127. doi:10.1111/jgs.15798. https://psne…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848082/psn-pdf
    April 26, 2023 - Adopting high reliability organization principles to lead a large scale clinical transformation. April 26, 2023 Pozzobon LD, Lam J, Chimonides E, et al. Adopting high reliability organization principles to lead a large scale clinical transformation. Healthc Manage Forum. 2023;36(4):241-245. doi:10.1177/08404704231…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44657/psn-pdf
    November 11, 2015 - Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for error reduction. November 11, 2015 Bruno MA, Walker EA, Abujudeh H. Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for error reduction. Radiographics. 2015;35(6):…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45278/psn-pdf
    September 07, 2016 - Medication double-checking procedures in clinical practice: a cross-sectional survey of oncology nurses' experiences. September 7, 2016 Schwappach DLB, Pfeiffer Y, Taxis K. Medication double-checking procedures in clinical practice: a cross- sectional survey of oncology nurses' experiences. BMJ Open. 2016;6(6). do…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851201/psn-pdf
    July 05, 2023 - ‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care. July 5, 2023 Gammon K. STAT. June 26, 2023. https://psnet.ahrq.gov/issue/i-felt-i-was-dying-how-women-postpartum-depression-fall-through-cracks-us- health-care The maternal mental health crisis results in …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843321/psn-pdf
    February 01, 2023 - Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. February 1, 2023 ISMP Medication Safety Alert! Acute care edition. January 12, 2023;28(1):1-4. https://psnet.ahrq.gov/issue/latent-and-active-failures-perfectly-align-allow-preventable-adverse-event- reach-patient …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38009/psn-pdf
    August 27, 2008 - Analysis of 23,364 patient-generated, physician-reviewed malpractice claims from a non-tort, blame-free, national patient insurance system: lessons learned from Sweden. August 27, 2008 Pukk-Härenstam K, Ask J, Brommels M, et al. Analysis of 23 364 patient-generated, physician-reviewed malpractice claims from a non…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838644/psn-pdf
    October 19, 2022 - Golden State Medical Supply, Inc. Issues a Voluntary Nationwide Recall of Atenolol 25 mg Tablets and Clopidogrel 75 mg Tablets Due to a Label Mix-up. October 19, 2022 MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 29, 2022. https://psnet.ahrq.gov/issue/golden-state-medical-sup…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46447/psn-pdf
    September 27, 2017 - Creating highly reliable accountable care organizations. September 27, 2017 Vogus TJ, Singer SJ. Creating Highly Reliable Accountable Care Organizations. Med Care Res Rev. 2016;73(6):660-672. https://psnet.ahrq.gov/issue/creating-highly-reliable-accountable-care-organizations High reliability is a goal throughout …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854246/psn-pdf
    October 04, 2023 - Inpatient EHR user experience and hospital EHR safety performance. October 4, 2023 Classen DC, Longhurst CA, Davis T, et al. Inpatient EHR user experience and hospital EHR safety performance. JAMA Netw Open. 2023;6(9):e2333152. doi:10.1001/jamanetworkopen.2023.33152. https://psnet.ahrq.gov/issue/inpatient-ehr-user…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43093/psn-pdf
    August 12, 2014 - Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids. August 12, 2014 Franklin BD, Panesar S, Vincent CA, et al. Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44351/psn-pdf
    October 21, 2015 - Heparin-containing medical devices and combination products: recommendations for labeling and safety testing. Draft guidance for industry and Food and Drug Administration staff. October 21, 2015 Federal Register. Washington, DC: US Department of Health and Human Services. Baltimore, MD: Food and Drug Administrati…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866355/psn-pdf
    July 24, 2024 - Frequency and preventability of adverse drug events in the outpatient setting. July 24, 2024 Wasserman RL, Edrees HH, Amato MG, et al. Frequency and preventability of adverse drug events in the outpatient setting. BMJ Qual Saf. 2024;Epub Jul 9. doi:10.1136/bmjqs-2024-017098. https://psnet.ahrq.gov/issue/frequency-…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44877/psn-pdf
    April 27, 2016 - Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices. April 27, 2016 Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16- 158. https://psnet.ahrq.gov/issue/actions-needed-help-ensure-appropriate-medication-continuation-and- pre…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45573/psn-pdf
    November 16, 2016 - High reliability of care in orthopedic surgery: are we there yet? November 16, 2016 Anoushiravani AA, Sayeed Z, El-Othmani MM, et al. High Reliability of Care in Orthopedic Surgery: Are We There Yet? Orthop Clin North Am. 2016;47(4):689-95. doi:10.1016/j.ocl.2016.05.011. https://psnet.ahrq.gov/issue/high-reliabili…
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