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Showing results for "implemented".

  1. Surgical intraoperative handoff initiative: standardizing operating room communication using SHRIMPS. | PSNet

    psnet.ahrq.gov/issue/surgical-intraoperative-handoff-initiative-standardizing-operating-room-communication-using
    October 04, 2023 - Study Surgical intraoperative handoff initiative: standardizing operating room communication using SHRIMPS. Citation Text: Stephens WA, Anderson MJ, Levy BE, et al. Surgical intraoperative handoff initiative: standardizing operating room communication using SHRIMPS. J Am Coll Surg. 2024;…

  2. Learning from no-fault treatment injury claims to improve the safety of older patients. | PSNet

    psnet.ahrq.gov/issue/learning-no-fault-treatment-injury-claims-improve-safety-older-patients
    September 27, 2023 - Study Learning from no-fault treatment injury claims to improve the safety of older patients. Citation Text: Wallis KA. Learning from no-fault treatment injury claims to improve the safety of older patients. Ann Fam Med. 2015;13(5):472-4. doi:10.1370/afm.1810. Copy Citation Format:…

  3. Defining the landscape of patient harm after osteopathic manipulative treatment: synthesis of an adverse event model. | PSNet

    psnet.ahrq.gov/issue/defining-landscape-patient-harm-after-osteopathic-manipulative-treatment-synthesis-adverse
    October 19, 2022 - Review Defining the landscape of patient harm after osteopathic manipulative treatment: synthesis of an adverse event model. Citation Text: Unger MD, Barr JN, Brower JA, et al. Defining the landscape of patient harm after osteopathic manipulative treatment: synthesis of an adverse event …

  4. Elucidating reasons for resident underutilization of electronic adverse event reporting. | PSNet

    psnet.ahrq.gov/issue/elucidating-reasons-resident-underutilization-electronic-adverse-event-reporting
    November 21, 2021 - Study Elucidating reasons for resident underutilization of electronic adverse event reporting. Citation Text: Hatoun J, Suen W, Liu C, et al. Elucidating Reasons for Resident Underutilization of Electronic Adverse Event Reporting. Am J Med Qual. 2016;31(4):308-314. doi:10.1177/1062860615…

  5. Minimising treatment-associated risks in systemic cancer therapy. | PSNet

    psnet.ahrq.gov/issue/minimising-treatment-associated-risks-systemic-cancer-therapy
    December 22, 2021 - Review Minimising treatment-associated risks in systemic cancer therapy. Citation Text: Jaehde U, Liekweg A, Simons S, et al. Minimising treatment-associated risks in systemic cancer therapy. Pharm World Sci. 2008;30(2):161-8. Copy Citation Format: Google Scholar PubMed B…

  6. When a surgical colleague makes an error. | PSNet

    psnet.ahrq.gov/issue/when-surgical-colleague-makes-error
    December 21, 2014 - Commentary When a surgical colleague makes an error. Citation Text: Antiel RM, Blinman TA, Rentea RM, et al. When a Surgical Colleague Makes an Error. Pediatrics. 2016;137(3):e20153828. doi:10.1542/peds.2015-3828. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNo…

  7. Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error. | PSNet

    psnet.ahrq.gov/issue/mortality-and-morbidity-rounds-mmr-pathology-relative-contribution-cognitive-bias-vs-systems
    May 18, 2022 - Study Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error. Citation Text: Eichbaum Q, Adkins B, Craig-Owens L, et al. Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias…

  8. Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project. | PSNet

    psnet.ahrq.gov/issue/improving-patient-safety-using-sterile-cockpit-principle-during-medication-administration
    September 12, 2016 - Study Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project. Citation Text: Fore AM, Sculli GL, Albee D, et al. Improving patient safety using the sterile cockpit principle during medication administration: a…

  9. From harm to hope and purposeful action: what could we do after Francis? | PSNet

    psnet.ahrq.gov/issue/harm-hope-and-purposeful-action-what-could-we-do-after-francis
    August 01, 2016 - Commentary From harm to hope and purposeful action: what could we do after Francis? Citation Text: Woodhead T, Lachman P, Mountford J, et al. From harm to hope and purposeful action: what could we do after Francis? BMJ Qual Saf. 2014;23(8):619-23. doi:10.1136/bmjqs-2013-002581. Copy Ci…

  10. Perception of patient safety culture in pediatric long-term care settings. | PSNet

    psnet.ahrq.gov/issue/perception-patient-safety-culture-pediatric-long-term-care-settings
    May 10, 2023 - Study Perception of patient safety culture in pediatric long-term care settings. Citation Text: Hessels AJ, Murray MT, Cohen B, et al. Perception of Patient Safety Culture in Pediatric Long-Term Care Settings. J Healthc Qual. 2018;40(6):384-391. doi:10.1097/JHQ.0000000000000134. Copy C…

  11. Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident study. | PSNet

    psnet.ahrq.gov/issue/understanding-causes-intravenous-medication-administration-errors-hospitals-qualitative
    June 25, 2014 - Study Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident study. Citation Text: Keers RN, Williams SD, Cooke J, et al. Understanding the causes of intravenous medication administration errors in hospitals: a qualitative c…

  12. Action research, simulation, team communication, and bringing the tacit into voice. Society for Simulation in Healthcare. | PSNet

    psnet.ahrq.gov/issue/action-research-simulation-team-communication-and-bringing-tacit-voice-society-simulation
    April 16, 2019 - Study Action research, simulation, team communication, and bringing the tacit into voice. Society for Simulation in Healthcare. Citation Text: Forsythe L. Action research, simulation, team communication, and bringing the tacit into voice society for simulation in healthcare. Simul Heal…

  13. The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives. | PSNet

    psnet.ahrq.gov/issue/henry-ford-health-system-no-harm-campaign-comprehensive-model-reduce-harm-and-save-lives
    May 11, 2019 - Commentary The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives. Citation Text: Conway WA, Hawkins S, Jordan J, et al. 2011 John M. Eisenberg Patient Safety and Quality Awards. The Henry Ford Health System No Harm Campaign: a comprehensive mo…

  14. Outcomes of missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis, and sepsis in five pediatric hospitals. | PSNet

    psnet.ahrq.gov/issue/outcomes-missed-diagnosis-pediatric-appendicitis-new-onset-diabetic-ketoacidosis-and-sepsis
    September 29, 2021 - Study Outcomes of missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis, and sepsis in five pediatric hospitals. Citation Text: Michelson KA, Bachur RG, Grubenhoff JA, et al. Outcomes of missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis, an…

  15. Radiologist age and diagnostic errors. | PSNet

    psnet.ahrq.gov/issue/radiologist-age-and-diagnostic-errors
    March 02, 2022 - Study Radiologist age and diagnostic errors. Citation Text: Lamoureux C, Hanna TN, Callaway E, et al. Radiologist age and diagnostic errors. Emerg Radiol. 2023;30(5):577-587. doi:10.1007/s10140-023-02158-1. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndN…

  16. Patient Safety Advisory: fentanyl counterfeit prescription medications that contain fentanyl and patient safety. | PSNet

    psnet.ahrq.gov/issue/patient-safety-advisory-fentanyl-counterfeit-prescription-medications-contain-fentanyl-and
    September 18, 2024 - Organizational Policy/Guidelines Patient Safety Advisory: fentanyl counterfeit prescription medications that contain fentanyl and patient safety. Citation Text: Jewell ML, Jewell HL, Singer R, et al. Patient Safety Advisory: fentanyl counterfeit prescription medications that contain fent…

  17. Physicians' practice of dispensing medicines: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/physicians-practice-dispensing-medicines-qualitative-study
    November 16, 2022 - Study Physicians' practice of dispensing medicines: a qualitative study. Citation Text: Darbyshire D, Gordon M, Baker P, et al. Physicians' Practice of Dispensing Medicines: A Qualitative Study. J Patient Saf. 2016;12(2):82-8. doi:10.1097/PTS.0000000000000122. Copy Citation Format:…

  18. Postdischarge adverse events for 1-day hospital admissions in older adults admitted from the emergency department. | PSNet

    psnet.ahrq.gov/issue/postdischarge-adverse-events-1-day-hospital-admissions-older-adults-admitted-emergency
    May 18, 2022 - Study Postdischarge adverse events for 1-day hospital admissions in older adults admitted from the emergency department. Citation Text: Pines JM, Mongelluzzo J, Hilton JA, et al. Postdischarge adverse events for 1-day hospital admissions in older adults admitted from the emergency depa…

  19. Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals. | PSNet

    psnet.ahrq.gov/issue/diet-order-entry-registered-dietitians-results-reduction-error-rates-and-time-delays-compared
    September 23, 2020 - Study Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals. Citation Text: Imfeld K, Keith M, Stoyanoff L, et al. Diet order entry by registered dietitians results in a reduction in error rates and time …

  20. Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. | PSNet

    psnet.ahrq.gov/issue/feedback-loop-failure-modes-medical-diagnosis-how-biases-can-emerge-and-be-reinforced
    November 01, 2023 - Study Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. Citation Text: Aikens RC, Chen JH, Baiocchi M, et al. Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. Med Decis Making. 2024;44(5):481-496. doi:10.1…
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