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Showing results for "identifying".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49855/psn-pdf
    March 01, 2019 - Which Line: Ordering Provider or Proceduralist? March 1, 2019 Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist Case Objectives Review the role of mistake-proofing to block errors from leading to adverse…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73642/psn-pdf
    August 25, 2021 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected August 25, 2021 Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect- unexpected …

  3. 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…

  4. 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…

  5. 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…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39317/psn-pdf
    November 02, 2010 - Exploring the causes of adverse events in hospitals and potential prevention strategies. November 2, 2010 Smits M, Zegers M, Groenewegen PP, et al. Exploring the causes of adverse events in hospitals and potential prevention strategies. BMJ Qual Saf. 2010;19(5). doi:10.1136/qshc.2008.030726. https://psnet.ahrq.gov…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35366/psn-pdf
    September 27, 2016 - Certified pharmacy technicians' views on their medication preparation errors and educational needs. September 27, 2016 Desselle SP. Certified pharmacy technicians' views on their medication preparation errors and educational needs. Am J Health Syst Pharm. 2005;62(19):1992-7. https://psnet.ahrq.gov/issue/certified-…

  8. 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…

  9. 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…

  10. 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…

  11. 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…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37002/psn-pdf
    September 14, 2011 - Factors influencing nurses' decisions to raise concerns about care quality. September 14, 2011 Attree M. Factors influencing nurses' decisions to raise concerns about care quality. J Nurs Manag. 2007;15(4):392-402. https://psnet.ahrq.gov/issue/factors-influencing-nurses-decisions-raise-concerns-about-care-quality …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41508/psn-pdf
    July 11, 2012 - Complications in surgery: root cause analysis and preventive measures. July 11, 2012 Chung KC, Kotsis S. Complications in surgery: root cause analysis and preventive measures. Plast Reconstr Surg. 2012;129(6):1421-1427. doi:10.1097/PRS.0b013e31824ecda0. https://psnet.ahrq.gov/issue/complications-surgery-root-cause…

  14. 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…

  15. 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…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37964/psn-pdf
    June 29, 2011 - Impact of miscommunication in medical dispute cases in Japan. June 29, 2011 Aoki N, Uda K, Ohta S, et al. Impact of miscommunication in medical dispute cases in Japan. Int J Qual Health Care. 2008;20(5):358-62. doi:10.1093/intqhc/mzn028. https://psnet.ahrq.gov/issue/impact-miscommunication-medical-dispute-cases-ja…

  17. 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…

  18. 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…

  19. 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…

  20. 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…
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