-
psnet.ahrq.gov/node/60883/psn-pdf
September 02, 2020 - When the misdiagnosis is child abuse.
September 2, 2020
Clifford S. When the misdiagnosis is child abuse. The Atlantic. 2020;August 20.
https://psnet.ahrq.gov/issue/when-misdiagnosis-child-abuse
Diagnostic decision-making is susceptible to cognitive biases and error in stressful situations. This feature
article il…
-
psnet.ahrq.gov/node/36383/psn-pdf
March 03, 2011 - Patterns of errors contributing to trauma mortality:
lessons learned from 2,594 deaths.
March 3, 2011
Gruen RL, Jurkovich GJ, McIntyre LK, et al. Patterns of Errors Contributing to Trauma Mortality.
Transactions of the .. Meeting of the American Surgical Association. 2006;124.
doi:10.1097/01.sla.0000234655.83517.5…
-
psnet.ahrq.gov/node/42214/psn-pdf
April 17, 2013 - This isn't my information! The impact of accurate identity
management on patient safety.
April 17, 2013
Garcia R. This isn't my information! The impact of accurate identity management on patient safety. Health
management technology. 2013;34(3):10-1.
https://psnet.ahrq.gov/issue/isnt-my-information-impact-accurate-…
-
psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - The first was documentation error on the medical records from Hospital A (identifying the tumor on the
-
psnet.ahrq.gov/node/49863/psn-pdf
May 01, 2019 - people-focused approaches.(9,10)
Concise, structured communication is essential in this process of identifying
-
psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
March 15, 2023 - Identifying symptoms and effects early and reacting to them is a core component. … the continued advancement in available technology and the innovations by the healthcare community in identifying … When designing the program, organizations must develop clear protocols for identifying appropriate patients
-
psnet.ahrq.gov/web-mm/duplicate-insulin-order
May 04, 2012 - orders following optimization interventions.( 10 ) These included drug-related interventions such as identifying
-
psnet.ahrq.gov/node/42869/psn-pdf
January 28, 2017 - Exploring Alternatives To Malpractice Litigation.
January 28, 2017
Improved safety, eliminating errors top policy agenda. Health Aff (Millwood). 2014;33(1):6-66.
https://psnet.ahrq.gov/issue/exploring-alternatives-malpractice-litigation
Articles in this special issue cover findings from a federally-funded initiativ…
-
psnet.ahrq.gov/node/37014/psn-pdf
September 15, 2011 - Medication safety messages for patients via the web
portal: the MedCheck intervention.
September 15, 2011
Weingart SN, Hamrick HE, Tutkus S, et al. Medication safety messages for patients via the web portal: the
MedCheck intervention. Int J Med Inform . 2008;77(3):161-168.
https://psnet.ahrq.gov/issue/medication-s…
-
psnet.ahrq.gov/node/34934/psn-pdf
March 11, 2011 - Exploring barriers and facilitators to the use of
computerized clinical reminders.
March 11, 2011
Saleem JJ, Patterson ES, Militello LG, et al. Exploring barriers and facilitators to the use of computerized
clinical reminders. J Am Med Inform Assoc. 2005;12(4):438-47.
https://psnet.ahrq.gov/issue/exploring-barrier…
-
psnet.ahrq.gov/node/35625/psn-pdf
June 22, 2010 - Improving the safety of medication administration using
an interactive CD-ROM program.
June 22, 2010
Schneider PJ, Pedersen CA, Montanya KR, et al. Improving the safety of medication administration using
an interactive CD-ROM program. Am J Health Syst Pharm. 2006;63(1):59-64.
https://psnet.ahrq.gov/issue/improving…
-
psnet.ahrq.gov/node/42814/psn-pdf
February 06, 2014 - Twelve tips on engaging learners in checking health care
decisions.
February 6, 2014
Sibbald M, de Bruin A, van Merrienboer JJG. Twelve tips on engaging learners in checking health care
decisions. Med Teach. 2014;36(2):111-5. doi:10.3109/0142159X.2013.847910.
https://psnet.ahrq.gov/issue/twelve-tips-engaging-learn…
-
psnet.ahrq.gov/node/44109/psn-pdf
November 06, 2015 - Safer Clinical Systems.
November 6, 2015
London, UK: Health Foundation.
https://psnet.ahrq.gov/issue/safer-clinical-systems
This Web site highlights the work of a United Kingdom initiative launched in 2008 to apply safety
improvement tactics from high-risk industries to care services. The program engages teams to …
-
psnet.ahrq.gov/node/42291/psn-pdf
September 12, 2016 - Human cognition and the dynamics of failure to rescue:
the Lewis Blackman case.
September 12, 2016
Acquaviva K, Haskell H, Johnson J. Human cognition and the dynamics of failure to rescue: the Lewis
Blackman case. J Prof Nurs. 2013;29(2):95-101. doi:10.1016/j.profnurs.2012.12.009.
https://psnet.ahrq.gov/issue/huma…
-
psnet.ahrq.gov/node/39609/psn-pdf
June 27, 2010 - Identification and Prevention of Common Adverse Drug
Events in the Intensive Care Unit.
June 27, 2010
Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(suppl 6):S83-S264.
https://psnet.ahrq.gov/issue/identification-and-prevention-common-adverse-drug-events-intensive-care-unit
This supplem…
-
psnet.ahrq.gov/node/45721/psn-pdf
June 28, 2017 - Rude providers jeopardize patient safety. So stop it.
June 28, 2017
Thew J. HealthLeaders Media. June 14, 2017.
https://psnet.ahrq.gov/issue/rude-providers-jeopardize-patient-safety-so-stop-it
Rudeness can affect teamwork and hinder safe, transparent care. This news article reports on one
hospital's approach to ma…
-
psnet.ahrq.gov/node/39324/psn-pdf
April 07, 2010 - Redesigning a morbidity and mortality program in a
university-affiliated pediatric anesthesia department.
April 7, 2010
McDonnell C, Laxer RM, Roy L. Redesigning a morbidity and mortality program in a university-affiliated
pediatric anesthesia department. Jt Comm J Qual Patient Saf. 2010;36(3):117-125.
https://psn…
-
psnet.ahrq.gov/node/36828/psn-pdf
August 29, 2011 - Pediatric medication errors in the postanesthesia care
unit: analysis of MEDMARX data.
August 29, 2011
Payne CH, Smith CR, Newkirk LE, et al. Pediatric medication errors in the postanesthesia care unit:
analysis of MEDMARX data. AORN J. 2007;85(4):731-40; quiz 741-4.
https://psnet.ahrq.gov/issue/pediatric-medicati…
-
psnet.ahrq.gov/node/39350/psn-pdf
March 10, 2010 - If only...: failed, missed and absent error recovery
opportunities in medication errors.
March 10, 2010
Habraken MMP, van der Schaaf TW. If only..: failed, missed and absent error recovery opportunities in
medication errors. Qual Saf Health Care. 2010;19(1):37-41. doi:10.1136/qshc.2007.026187.
https://psnet.ahrq.g…
-
psnet.ahrq.gov/node/41254/psn-pdf
April 11, 2012 - The Daily Plan: including patients for safety's sake.
April 11, 2012
King BJ, Mills PD, Fore AM, et al. The Daily Plan®: Including patients for safety's sake. Nurs Manage.
2012;43(3):15-8. doi:10.1097/01.NUMA.0000412229.53136.3e.
https://psnet.ahrq.gov/issue/daily-plan-including-patients-safetys-sake
This study re…