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5461. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected | PSNet
      psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
      September 25, 2024 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected Citation Text: Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…

5462. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49681/psn-pdf
      April 01, 2013 - Total Parenteral Nutrition, Multifarious Errors April 1, 2013 Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors Case Objectives Define parenteral nutrition (PN). Describe the PN-use process. Identify …

5463. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49858/psn-pdf
      April 01, 2019 - Each facility is responsible for identifying the response process.

5464. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35015/psn-pdf
      June 16, 2011 - Keeping Patients Safe: Transforming the Work Environment of Nurses. June 16, 2011 Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services. Washington, DC: The National Academies Press; 2004. ISBN: 9780309090674. https://psnet.ahrq.gov/issue/keeping-patients-safe-trans…

5465. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836868/psn-pdf
      April 06, 2022 - HEAR Her Concerns. April 6, 2022 National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; Centers for Disease Control and Prevention.  https://psnet.ahrq.gov/issue/hear-her-concerns Maternal harm during and after pregnancy is a sentinel event. This campaign encoura…

5466. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45590/psn-pdf
      August 02, 2017 - Improving Diagnostic Accuracy Project 2016–2017. August 2, 2017 Washington, DC: National Quality Forum; October 2016. https://psnet.ahrq.gov/issue/improving-diagnostic-accuracy-project-2016-2017 The Improving Diagnosis in Health Care report provided recommendations to help achieve safe, reliable diagnosis. This we…

5467. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39296/psn-pdf
      January 22, 2017 - Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. January 22, 2017 Aboumatar HJ, Winner L, Davis RO, et al. Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. Jt Comm J Qual Patient Saf. 2010;36(2):79-86. https://psnet.ahrq.gov/issue/applying-lea…

5468. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34636/psn-pdf
      June 14, 2011 - The wrong patient. June 14, 2011 Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136(11):826-833. https://psnet.ahrq.gov/issue/wrong-patient This case study describes the events of a patient who underwent an unintended invasive cardiac electrophysiology study. While reviewing the details of the case…

5469. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841773/psn-pdf
      December 21, 2022 - Inappropriate prescribing of opioids for patients undergoing surgery. December 21, 2022 Varady NH, Worsham CM, Chen AF, et al. Inappropriate prescribing of opioids for patients undergoing surgery. Proc Natl Acad Sci USA. 2022;119(49):e2210226119. doi:10.1073/pnas.2210226119. https://psnet.ahrq.gov/issue/inappropri…

5470. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42387/psn-pdf
      December 30, 2014 - 'Bad apples': time to redefine as a type of systems problem? December 30, 2014 Shojania KG, Dixon-Woods M. 'Bad apples': time to redefine as a type of systems problem? BMJ Qual Saf. 2013;22(7):528-531. doi:10.1136/bmjqs-2013-002138. https://psnet.ahrq.gov/issue/bad-apples-time-redefine-type-systems-problem While …

5471. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36381/psn-pdf
      April 22, 2011 - Accountability sought by patients following adverse events from medical care: the New Zealand experience. April 22, 2011 Bismark M, Dauer E, Paterson R, et al. Accountability sought by patients following adverse events from medical care: the New Zealand experience. CMAJ. 2006;175(8):889-94. https://psnet.ahrq.gov/…

5472. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45450/psn-pdf
      February 13, 2018 - Avoiding Unconscious Bias: a Guide for Surgeons. February 13, 2018 London, UK: Royal College of Surgeons of England; 2016. https://psnet.ahrq.gov/issue/avoiding-unconscious-bias-guide-surgeons Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides information for sur…

5473. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46385/psn-pdf
      October 23, 2018 - The key to reducing doctors' misdiagnoses. October 23, 2018 Landro L. Wall Street Journal. September 12, 2017. https://psnet.ahrq.gov/issue/key-reducing-doctors-misdiagnoses Misdiagnosis has gained recognition as an important patient safety problem. This newspaper article reports on several areas of research and i…

5474. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37850/psn-pdf
      June 18, 2008 - Information technology-based approaches to reducing repeat drug exposure in patients with known drug allergies. June 18, 2008 Cresswell K, Sheikh A. Information technology-based approaches to reducing repeat drug exposure in patients with known drug allergies. J Allergy Clin Immunol. 2008;121(5):1112-1117.e7. doi…

5475. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37367/psn-pdf
      May 26, 2011 - Reasons provided by prescribers when overriding drug–drug interaction alerts. May 26, 2011 Grizzle AJ, Mahmood MH, Ko Y, et al. Reasons provided by prescribers when overriding drug-drug interaction alerts. Am J Manag Care. 2007;13(10):573-578. https://psnet.ahrq.gov/issue/reasons-provided-prescribers-when-overridi…

5476. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41396/psn-pdf
      May 23, 2012 - In search of common ground in handoff documentation in an intensive care unit. May 23, 2012 Collins S, Mamykina L, Jordan D, et al. In search of common ground in handoff documentation in an Intensive Care Unit. J Biomed Inform. 2012;45(2):307-15. doi:10.1016/j.jbi.2011.11.007. https://psnet.ahrq.gov/issue/search-c…

5477. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44097/psn-pdf
      June 10, 2015 - Hospital nurses' perceptions of human factors contributing to nursing errors. June 10, 2015 Roth C, Wieck L, Fountain R, et al. Hospital nurses' perceptions of human factors contributing to nursing errors. J Nurs Adm. 2015;45(5):263-9. doi:10.1097/NNA.0000000000000196. https://psnet.ahrq.gov/issue/hospital-nurses-…

5478. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38656/psn-pdf
      May 27, 2009 - Pediatric safety incidents from an intensive care reporting system. May 27, 2009 Skapik JL; Pronovost PJ; Miller MR; Thompson DA; Wu AW. https://psnet.ahrq.gov/issue/pediatric-safety-incidents-intensive-care-reporting-system The Intensive Care Unit Safety Reporting System (ICUSRS) is a model incident reporting sys…

5479. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41896/psn-pdf
      December 12, 2012 - Bar-code verification: reducing but not eliminating medication errors. December 12, 2012 Henneman PL, Marquard J, Fisher DL, et al. Bar-code verification: reducing but not eliminating medication errors. J Nurs Adm. 2012;42(12):562-6. doi:10.1097/NNA.0b013e318274b545. https://psnet.ahrq.gov/issue/bar-code-verificat…

5480. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39050/psn-pdf
      January 04, 2010 - Safety as a criterion for quality: The Critical Nursing Situation Index in paediatric critical care, an observational study. January 4, 2010 de Neef M, Bos AP, Tol D. Safety as a criterion for quality: the critical nursing situation index in paediatric critical care, an observational study. Intensive Crit Care Nur…