Results

Total Results: over 10,000 records

Showing results for "identifying".

4921. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34623/psn-pdf
      January 28, 2015 - Australian Commission on Safety and Quality in Health Care. January 28, 2015 Australian Commission for Safety and Quality in Health Care. https://psnet.ahrq.gov/issue/australian-commission-safety-and-quality-health-care Established in January 2006, the Commission leads and coordinates improvements in safety and qu…

4922. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36146/psn-pdf
      February 05, 2019 - Guidelines for Design and Construction. February 5, 2019 St Louis, Missouri; Facilities Guidelines Institute; 2018. https://psnet.ahrq.gov/issue/guidelines-design-and-construction These updated guidelines include design changes, such as the adoption of private rooms to reduce medical error, interruptions, and hosp…

4923. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34099/psn-pdf
      March 02, 2016 - Findings from the ISMP Medication Safety Self- Assessment for hospitals. March 2, 2016 Smetzer JL, Vaida AJ, Cohen MR, et al. Findings from the ISMP Medication Safety Self-Assessment for hospitals. Jt Comm J Qual Patient Saf. 2003;29(11):586-597. https://psnet.ahrq.gov/issue/findings-ismp-medication-safety-self-as…

4924. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42712/psn-pdf
      October 02, 2017 - Improving patient safety through transparency. October 2, 2017 Kachalia A. Improving patient safety through transparency. N Engl J Med. 2013;369(18):1677-9. doi:10.1056/NEJMp1303960. https://psnet.ahrq.gov/issue/improving-patient-safety-through-transparency This commentary describes successful transparency initiat…

4925. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39196/psn-pdf
      January 16, 2010 - Detecting adverse events in dermatologic surgery. January 16, 2010 Pinney D, Pearce DJ, Feldman SR. Detecting adverse events in dermatologic surgery. Dermatol Surg. 2010;36(1):8-14. doi:10.1111/j.1524-4725.2009.01378.x. https://psnet.ahrq.gov/issue/detecting-adverse-events-dermatologic-surgery This review identifi…

4926. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36127/psn-pdf
      September 29, 2010 - Fatality involving vinblastine overdose as a result of a complex medical error. September 29, 2010 K?ys M, Konopka T, Scis?owski M, et al. Fatality involving vinblastine overdose as a result of a complex medical error. Cancer Chemother Pharmacol. 2007;59(1):89-95. https://psnet.ahrq.gov/issue/fatality-involving-vi…

4927. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42772/psn-pdf
      January 01, 2014 - Hard Truths: the Journey to Putting Patients First. November 27, 2013 Department of Health. London, England: Crown Publishing; January 2014. ISBN: 9780101877725. https://psnet.ahrq.gov/issue/hard-truths-journey-putting-patients-first This two-part report outlines actions that health care leaders in the United Kingd…

4928. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36845/psn-pdf
      August 29, 2011 - Near miss audit in obstetrics. August 29, 2011 Penney G, Brace V. Near miss audit in obstetrics. Curr Opin Obstet Gynecol. 2007;19(2):145-150. https://psnet.ahrq.gov/issue/near-miss-audit-obstetrics Reviewing studies about maternal morbidity, the authors discuss the various measurement approaches used to identify …

4929. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39780/psn-pdf
      January 04, 2017 - The First Annual HealthGrades Pediatric Patient Safety in American Hospitals Study. January 4, 2017 Reed K, May R. Golden, CO: Health Grades, Inc; 2010. https://psnet.ahrq.gov/issue/first-annual-healthgrades-pediatric-patient-safety-american-hospitals-study This report analyzed Agency for Healthcare Research and Q…

4930. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35469/psn-pdf
      January 21, 2011 - Neurologic patient safety: an in-depth study of malpractice claims. January 21, 2011 Glick TH, Cranberg LD, Hanscom RB, et al. Neurologic patient safety: an in-depth study of malpractice claims. Neurology. 2005;65(8):1284-6. https://psnet.ahrq.gov/issue/neurologic-patient-safety-depth-study-malpractice-claims The…

4931. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36683/psn-pdf
      March 28, 2011 - Adverse events following an emergency department visit. March 28, 2011 Forster AJ, Rose NGW, van Walraven C, et al. Adverse events following an emergency department visit. Qual Saf Health Care. 2007;16(1):17-22. https://psnet.ahrq.gov/issue/adverse-events-following-emergency-department-visit The investigators inte…

4932. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40157/psn-pdf
      January 19, 2011 - Instrument readiness: an important link to patient safety. January 19, 2011 McNamara SA. Instrument readiness: an important link to patient safety. AORN J. 2011;93(1):160-4. doi:10.1016/j.aorn.2010.09.027. https://psnet.ahrq.gov/issue/instrument-readiness-important-link-patient-safety This commentary reviews steps…

4933. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42561/psn-pdf
      October 09, 2013 - Defining technical errors in laparoscopic surgery: a systematic review. October 9, 2013 Bonrath EM, Dedy NJ, Zevin B, et al. Defining technical errors in laparoscopic surgery: a systematic review. Surg Endosc. 2013;27(8):2678-91. doi:10.1007/s00464-013-2827-5. https://psnet.ahrq.gov/issue/defining-technical-errors…

4934. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41160/psn-pdf
      February 22, 2012 - Surgical count practice variability and the potential for retained surgical items. February 22, 2012 Edel EM. Surgical count practice variability and the potential for retained surgical items. AORN J. 2012;95(2):228-38. doi:10.1016/j.aorn.2011.02.014. https://psnet.ahrq.gov/issue/surgical-count-practice-variabilit…

4935. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42600/psn-pdf
      September 18, 2013 - Oral medications inadvertently given via the intravenous route. September 18, 2013 Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91. https://psnet.ahrq.gov/issue/oral-medications-inadvertently-given-intravenous-route Analyzing data submitted to the Pennsylvania Patient Safety Reporti…

4936. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42310/psn-pdf
      June 10, 2018 - Administering a saline flush "site unseen" can lead to a wrong route error. June 10, 2018 ISMP Medication Safety Alert! Acute care edition. May 16, 2013;18:1-3. https://psnet.ahrq.gov/issue/administering-saline-flush-site-unseen-can-lead-wrong-route-error Describing a tubing misconnection error, this newsletter id…

4937. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50896/psn-pdf
      February 12, 2020 - Medical abbreviations that have contradictory or ambiguous meanings. February 12, 2020 Davis N. ISMP Medication Safety Alert! Acute care edition! January 30, 2020;25(2):1-5. https://psnet.ahrq.gov/issue/medical-abbreviations-have-contradictory-or-ambiguous-meanings Multiple organizations have identified using…

4938. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38130/psn-pdf
      January 02, 2017 - View the world through a different lens: shadowing another provider. January 2, 2017 Thompson DA, Holzmueller CG, Lubomski LH, et al. View the world through a different lens: shadowing another provider. Jt Comm J Qual Patient Saf. 2008;34(10):614-8, 561. https://psnet.ahrq.gov/issue/view-world-through-different-le…

4939. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39882/psn-pdf
      January 19, 2011 - Incidence and types of non-ideal care events in an emergency department. January 19, 2011 Hall KK, Schenkel SM, Hirshon JM, et al. Incidence and types of non-ideal care events in an emergency department. Qual Saf Health Care. 2010;19 Suppl 3:i20-5. doi:10.1136/qshc.2010.040246. https://psnet.ahrq.gov/issue/inciden…

4940. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73548/psn-pdf
      July 27, 2021 - Diagnostic Errors in Primary Care. July 27, 2021 Betsy Lehman Center for Patient Safety. https://psnet.ahrq.gov/issue/diagnostic-errors-primary-care Case analysis provides important opportunities to highlight factors that culminate in diagnostic error. This website supports learning generated from the Primary-Care…