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8761. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety | PSNet
      psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
      March 01, 2017 - Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety Sara J. Singer, MBA, PhD | March 1, 2017  Also Read a Conversation View more articles from the same authors. Citation Text: Singer SJ. Our Maturing Understanding of Safety C…

8762. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40703/psn-pdf
      August 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…

8763. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42718/psn-pdf
      September 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…

8764. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37085/psn-pdf
      July 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…

8765. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35702/psn-pdf
      May 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…

8766. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38230/psn-pdf
      August 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…

8767. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39589/psn-pdf
      February 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…

8768. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37229/psn-pdf
      November 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…

8769. What Have We Learned About Safe Inpatient Handovers? | PSNet
      psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
      March 01, 2011 - What Have We Learned About Safe Inpatient Handovers? Sunil Kripalani, MD, MSc | March 1, 2011  Also Read a Conversation View more articles from the same authors. Citation Text: Kripalani S. What Have We Learned About Safe Inpatient Handovers?. PSNet [internet]. …

8770. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33997/psn-pdf
      March 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…

8771. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37341/psn-pdf
      January 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…

8772. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36869/psn-pdf
      August 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…

8773. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36757/psn-pdf
      August 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…

8774. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41365/psn-pdf
      May 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 …

8775. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35004/psn-pdf
      May 18, 2005 - Lean Six Sigma reduces medication errors. May 18, 2005 Esimai G. Quality Progress; 2005;38(4):51-57. https://psnet.ahrq.gov/issue/lean-six-sigma-reduces-medication-errors The authors analyze one hospital’s quality management program. Using a Six Sigma methodology, the program identified policy and practice changes…

8776. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42167/psn-pdf
      April 03, 2013 - Engaging Patients in Improving Ambulatory Care. April 3, 2013 Aligning Forces for Quality. Princeton, NJ: Robert Wood Johnson Foundation; 2013. https://psnet.ahrq.gov/issue/engaging-patients-improving-ambulatory-care This compendium includes strategies and tools to engage patients in health care improvement that ha…

8777. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39538/psn-pdf
      May 19, 2010 - CPOE: strategies for success. May 19, 2010 Manor PJ. CPOE: Strategies for success. Nurs Manage. 2010;41(5):18-20. doi:10.1097/01.NUMA.0000372028.99240.7f. https://psnet.ahrq.gov/issue/cpoe-strategies-success This commentary reviews tactics to engage nurses in computerized provider order entry (CPOE) implementatio…

8778. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39815/psn-pdf
      March 18, 2011 - Introducing new technology safely. March 18, 2011 Mytton OT, Velazquez A, Banken R, et al. Introducing new technology safely. Qual Saf Health Care. 2010;19 Suppl 2:i9-14. doi:10.1136/qshc.2009.038554. https://psnet.ahrq.gov/issue/introducing-new-technology-safely This report describes the distinction between techn…

8779. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35422/psn-pdf
      June 17, 2014 - Medication safety issue brief. Medication reconciliation. June 17, 2014 Hosp Health Netw. 2005 Sep;79(9):33-34. https://psnet.ahrq.gov/issue/medication-safety-issue-brief-medication-reconciliation This issue brief provides case studies from hospitals that have successfully implemented medication reconciliation pro…

8780. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40139/psn-pdf
      January 22, 2017 - Standardizing hospital discharge planning at the Mayo Clinic. January 22, 2017 Holland DE, Hemann MA. Standardizing hospital discharge planning at the Mayo Clinic. Jt Comm J Qual Patient Saf. 2011;37(1):29-36. https://psnet.ahrq.gov/issue/standardizing-hospital-discharge-planning-mayo-clinic Implementation of a s…