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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37152/psn-pdfSeptember 05, 2007 - Why pay for mistakes? September 5, 2007 https://psnet.ahrq.gov/issue/why-pay-mistakes Recently, CMS ruled that Medicare will no longer cover certain preventable errors. In this op-ed piece, the author discusses why this new rule will drive hospitals to implement safety measures. https://psnet.ahrq.gov/issue/why-pa… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33938/psn-pdfDecember 18, 2008 - Dana-Farber Cancer Institute Principles of a Fair and Just Culture. December 18, 2008 Dana-Farber Cancer Institute. https://psnet.ahrq.gov/issue/dana-farber-cancer-institute-principles-fair-and-just-culture Dana-Farber Cancer Institute defines a "just culture" and illustrates how to implement and sustain it. http… -
Spotlight Case [MONTH] 2003 (ppt file)
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.pptNovember 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case November 2006 Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Source and Credits This presentation is based on the November 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49770/psn-pdfSeptember 01, 2016 - Wrong-Time Error With High-Alert Medication September 1, 2016 Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication The Case A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th… -
Spotlight Case (ppt file)
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.pptAugust 01, 2012 - Spotlight Case Spotlight Case No News May Not Be Good News 1 2 Source and Credits This presentation is based on the August 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicin… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37073/psn-pdfAugust 01, 2007 - An Amendment of the Medical Care Availability and Reduction of Error (Mcare) Act. August 1, 2007 Pennsylvania General Assembly. https://psnet.ahrq.gov/issue/amendment-medical-care-availability-and-reduction-error-mcare-act This bill requires that Pennsylvania hospitals and nursing homes implement an internal infec… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35249/psn-pdfMarch 04, 2011 - The patient safety story. March 4, 2011 Elwyn G, Corrigan JM. The patient safety story. BMJ. 2005;331(7512):302-304. doi:10.1136/bmj.38562.690104.43. https://psnet.ahrq.gov/issue/patient-safety-story The authors provide a brief history of the patient safety movement and insights into why the time is right to impl… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37085/psn-pdfJuly 15, 2013 - Critical Care Safety: Essentials for ICU Patient Care and Technology. July 15, 2013 Plymouth Meeting PA: ECRI Institute; 2007. ISBN 9780977914258. https://psnet.ahrq.gov/issue/critical-care-safety-essentials-icu-patient-care-and-technology This guide provides comprehensive tools for assessment, training, and imple… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37229/psn-pdfNovember 28, 2007 - Many Mass. hospitals will pay for errors. November 28, 2007 Kowalczyk L. https://psnet.ahrq.gov/issue/many-mass-hospitals-will-pay-errors This article reports on how numerous Massachusetts hospitals have implemented policies to waive charges for the set of serious errors categorized as never events. https://psnet… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42718/psn-pdfSeptember 17, 2018 - A Culture of Safety in EMS Systems. September 17, 2018 Irving, TX: American College of Emergency Physicians; 2014. https://psnet.ahrq.gov/issue/culture-safety-ems-systems This guidance recognizes risks associated with emergency medical services and provides recommendations to support the implementation of a safety… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39589/psn-pdfFebruary 13, 2018 - Common cause analysis. February 13, 2018 Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35. https://psnet.ahrq.gov/issue/common-cause-analysis This article describes how one health care system used a multi-event analysis process to identify medication errors, implement system-level improvements, a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35702/psn-pdfMay 30, 2008 - The Prescription Infrastructre: Are We Ready for ePrescribing? May 30, 2008 Sarasohn-Kahn J, Holt M. Oakland, CA: California Healthcare Foundation; 2006. ISBN 1933795026. https://psnet.ahrq.gov/issue/prescription-infrastructre-are-we-ready-eprescribing This report outlines the prescription process and the potentia… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40703/psn-pdfAugust 17, 2011 - Washington Hospital Center safety program seeks to catch 'near-misses.' August 17, 2011 Sun LH. https://psnet.ahrq.gov/issue/washington-hospital-center-safety-program-seeks-catch-near-misses This newspaper article reports on one hospital's implementation of an alert system designed to encourage frontline personne… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38230/psn-pdfAugust 11, 2010 - The Patient Safety Leadership WalkRounds Guide. August 11, 2010 Frankel AS, Grillo S, Pittman MA. Chicago, IL: Health Research and Educational Trust; 2006. https://psnet.ahrq.gov/issue/patient-safety-leadership-walkrounds-guide This booklet provides information on the implementation of a WalkRounds program as a cul… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60542/psn-pdfMay 27, 2020 - Life-Threatening Infant Overdose of Sodium Chloride May 27, 2020 Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride The Case An infant with trisomy 21 underwent repair of a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36869/psn-pdfAugust 31, 2011 - An extra dose of safety. August 31, 2011 An extra dose of safety. Installation of a bar-coding system drives an entire workflow redesign at a non- profit hospital and healthcare network. Health management technology. 2007;28(4):30-2, 34. https://psnet.ahrq.gov/issue/extra-dose-safety This article describes a healt… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37341/psn-pdfJanuary 20, 2010 - Patient-Centered Care: What Does It Take? January 20, 2010 Shaller D. The Commonwealth Fund. October 2007. https://psnet.ahrq.gov/issue/patient-centered-care-what-does-it-take By sharing the insights of health care leaders, this report identifies important factors for integrating patient- centered care into organi… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33997/psn-pdfMarch 17, 2011 - Maryland/DC Patient Safety Coalition. March 17, 2011 https://psnet.ahrq.gov/issue/marylanddc-patient-safety-coalition The Maryland Patient Safety Center facilitates the study of unsafe practices and the implementation of practical improvements to prevent errors. The center is a collaboration of two organizations th… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36757/psn-pdfAugust 09, 2011 - Medication bar coding: to scan or not to scan? August 9, 2011 Galvin L, McBeth S, Hasdorff C, et al. Medication bar coding: to scan or not to scan? Comput Inform Nurs. 2007;25(2):86-92. https://psnet.ahrq.gov/issue/medication-bar-coding-scan-or-not-scan The authors describe the implementation of a bedside medicati… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41365/psn-pdfMay 09, 2012 - Patient safety: break the silence. May 9, 2012 Johnson HL, Kimsey D. Patient safety: break the silence. AORN J. 2012;95(5):591-601. doi:10.1016/j.aorn.2012.03.002. https://psnet.ahrq.gov/issue/patient-safety-break-silence This commentary describes the development, implementation, and impact of a team-based safety …
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