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Showing results for "implementing".

8001. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60257/psn-pdf
      April 23, 2020 - When We Do Harm: A Doctor Confronts Medical Error. April 23, 2020 Ofri D. Boston, MA: Beacon Press; 2020. ISBN 9780807037881. https://psnet.ahrq.gov/issue/when-we-do-harm-doctor-confronts-medical-error Human and system failures combine to result in preventable patient harm. This book highlights the need for frontl…

8002. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865348/psn-pdf
      January 01, 2023 - Learning Health Systems January 1, 2023 Agency for Health Research and Quality. https://psnet.ahrq.gov/issue/learning-health-systems The learning health system model centers on the purposeful, systematic use of internal data and knowledge with external evidence to improve the safety and quality of care. This websi…

8003. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42563/psn-pdf
      October 09, 2013 - Quick Response codes for surgical safety: a prospective pilot study. October 9, 2013 Dixon JL, Smythe WR, Momsen LS, et al. Quick Response codes for surgical safety: a prospective pilot study. Journal of Surgical Research. 2013;184(1). doi:10.1016/j.jss.2013.06.036. https://psnet.ahrq.gov/issue/quick-response-code…

8004. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38698/psn-pdf
      June 10, 2009 - Towards a framework to select techniques for error prediction: supporting novice users in the healthcare sector. June 10, 2009 Lyons M. Towards a framework to select techniques for error prediction: supporting novice users in the healthcare sector. Appl Ergon. 2009;40(3):379-95. doi:10.1016/j.apergo.2008.11.004. …

8005. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42460/psn-pdf
      July 31, 2013 - Effectiveness of the surgical safety checklist in a high standard care environment. July 31, 2013 Lübbeke A, Hovaguimian F, Wickboldt N, et al. Effectiveness of the surgical safety checklist in a high standard care environment. Med Care. 2013;51(5):425-9. doi:10.1097/MLR.0b013e31828d1489. https://psnet.ahrq.gov/is…

8006. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42668/psn-pdf
      January 09, 2014 - Delayed medical emergency team calls and associated outcomes. January 9, 2014 Boniatti MM, Azzolini N, Viana M, et al. Delayed medical emergency team calls and associated outcomes. Crit Care Med. 2014;42(1):26-30. doi:10.1097/CCM.0b013e31829e53b9. https://psnet.ahrq.gov/issue/delayed-medical-emergency-team-calls-a…

8007. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37432/psn-pdf
      November 29, 2009 - The Pennsylvania Learning Exchange: Helping States Improve and Integrate Patient Safety Initiatives—Summary Report. November 29, 2009 Hanlon C; Rosenthal J. Portland, ME: National Academy for State Health Policy; 2007. https://psnet.ahrq.gov/issue/pennsylvania-learning-exchange-helping-states-improve-and-integrate…

8008. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74095/psn-pdf
      February 01, 2022 - Zero Suicide Initiative. November 17, 2021 Office of the Federal Register, National Archives and Records Administration. Fed Register. November 3, 2021;(86):60883-60893. https://psnet.ahrq.gov/issue/zero-suicide-initiative Patient suicide attempts are considered never events. This funding announcement calls for pr…

8009. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46055/psn-pdf
      July 26, 2017 - Bridging the gap between work-as-imagined and work-as- done. July 26, 2017 Deutsch ES. PA-PSRS Patient Saf Advis. June 2017;14:80-83. https://psnet.ahrq.gov/issue/bridging-gap-between-work-imagined-and-work-done Understanding what is possible in the context of frontline practice is key when designing enhancements …

8010. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37887/psn-pdf
      July 02, 2008 - Medical mistakes no longer billable: bold steps taken by state to reduce hospital errors. July 2, 2008 Smith S. https://psnet.ahrq.gov/issue/medical-mistakes-no-longer-billable-bold-steps-taken-state-reduce-hospital- errors Massachusetts government and state insurers have outlined policies whereby they will not r…

8011. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43322/psn-pdf
      January 28, 2015 - Patient Safety Initiative: Hospital Executive and Physician Leadership Strategies. January 28, 2015 Oakbrook, IL: Joint Commission Resources; January 2014. https://psnet.ahrq.gov/issue/patient-safety-initiative-hospital-executive-and-physician-leadership-strategies This toolkit draws from experiences of the Joint …

8012. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36425/psn-pdf
      December 22, 2010 - Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors. December 22, 2010 Wagar EA, Tamashiro L, Yasin B, et al. Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors. Arch Pathol Lab Med. 2006;130(11):1662-1668. https://p…

8013. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40155/psn-pdf
      January 26, 2011 - Addressing safety concerns about U-500 insulin in a hospital setting. January 26, 2011 Samaan KH, Dahlke M, Stover J. Addressing safety concerns about U-500 insulin in a hospital setting. Am J Health Syst Pharm. 2011;68(1):63-8. doi:10.2146/ajhp100224. https://psnet.ahrq.gov/issue/addressing-safety-concerns-about-…

8014. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35271/psn-pdf
      June 29, 2009 - Use of specific indicators to detect warfarin-related adverse events.   June 29, 2009 Hartis CE, Gum MO, Lederer JW. Use of specific indicators to detect warfarin-related adverse events. American Journal of Health-System Pharmacy. 2005;62(16). doi:10.2146/ajhp040404. https://psnet.ahrq.gov/issue/use-specific-indic…

8015. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41340/psn-pdf
      January 03, 2017 - How to develop a second victim support program: a toolkit for health care organizations. January 3, 2017 Pratt SD, Kenney L, Scott SD, et al. How to develop a second victim support program: a toolkit for health care organizations. Jt Comm J Qual Patient Saf. 2012;38(5):235-40, 193. https://psnet.ahrq.gov/issue/how…

8016. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36688/psn-pdf
      May 27, 2011 - Prevention of potential errors in resuscitation medications orders by means of a computerised physician order entry in paediatric critical care. May 27, 2011 Vardi A; Efrati O; Levin I; Matok I; Rubinstein M; Paret G; Barzilay Z. https://psnet.ahrq.gov/issue/prevention-potential-errors-resuscitation-medications-or…

8017. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37919/psn-pdf
      July 16, 2008 - Adverse event protocol for interventional pain medicine: the importance of an organized response. July 16, 2008 Sitzman BT. Adverse Event Protocol for Interventional Pain Medicine: The Importance of an Organized Response. Pain Medicine. 2008;9(suppl 1). doi:10.1111/j.1526-4637.2008.00446.x. https://psnet.ahrq.gov/…

8018. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42537/psn-pdf
      October 02, 2013 - The use of a checklist in a pediatric oncology clinic. October 2, 2013 McLean TW, White GM, Bagliani AF, et al. The use of a checklist in a pediatric oncology clinic. Pediatr Blood Cancer. 2013;60(11):1855-9. doi:10.1002/pbc.24657. https://psnet.ahrq.gov/issue/use-checklist-pediatric-oncology-clinic An Institute o…

8019. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43864/psn-pdf
      January 28, 2015 - Starter Kit for Alarm Fatigue. January 28, 2015 National Association of Clinical Nurse Specialists; NACNS. https://psnet.ahrq.gov/issue/starter-kit-alarm-fatigue Alarm fatigue has been identified as a serious problem that affects the safety of nursing care. This toolkit provides checklists, resources, and implemen…

8020. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47354/psn-pdf
      November 21, 2018 - Improving Diagnosis in Medicine Change Package. November 21, 2018 Chicago, IL: Health Research & Educational Trust; 2018. https://psnet.ahrq.gov/issue/improving-diagnosis-medicine-change-package Proactive identification of conditions that degrade the diagnostic process can drive improvement. This toolkit provides …