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Showing results for "implementing".

9021. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35311/psn-pdf
      January 02, 2017 - Medication dosing errors for patients with renal insufficiency in ambulatory care. January 2, 2017 Yap C, Dunham D, Thompson JA, et al. Medication Dosing Errors for Patients with Renal Insufficiency in Ambulatory Care. The Joint Commission Journal on Quality and Patient Safety. 2016;31(9). doi:10.1016/s1553-7250(0…

9022. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73897/psn-pdf
      September 29, 2021 - Peer Support Toolkit. September 29, 2021 Betsy Lehman Center for Patient Safety. September 2021. https://psnet.ahrq.gov/issue/peer-support-toolkit Clinicians involved in adverse events that harm patients can struggle to come to terms with error. This toolkit is designed to assist organizations in the development o…

9023. 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…

9024. 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 …

9025. 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 …

9026. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37780/psn-pdf
      March 10, 2011 - Evaluation of an inpatient computerized medication reconciliation system. March 10, 2011 Turchin A, Hamann C, Schnipper JL, et al. Evaluation of an inpatient computerized medication reconciliation system. J Am Med Inform Assoc. 2008;15(4):449-52. doi:10.1197/jamia.M2561. https://psnet.ahrq.gov/issue/evaluation-inp…

9027. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38532/psn-pdf
      January 13, 2017 - Triggers and Targeted Injury Detection Systems (TIDS) Expert Panel Meeting: Conference Summary Report. January 13, 2017 Rockville, MD: Agency for Healthcare Research and Quality; February 2009. AHRQ Publication No. 090003. https://psnet.ahrq.gov/issue/triggers-and-targeted-injury-detection-systems-tids-expert-pane…

9028. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73451/psn-pdf
      June 30, 2021 - National Patient Safety Syllabus. June 30, 2021 Spurgeon P, Cross S. London, UK; Academy of Medical Royal Colleges: May 2021. https://psnet.ahrq.gov/issue/national-patient-safety-syllabus Amending curricula to incorporate the increasing scholarship related to patient safety improvement is a challenge. This st…

9029. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50874/psn-pdf
      February 05, 2020 - Checking In on the Checklist. February 5, 2020 Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020. https://psnet.ahrq.gov/issue/checking-checklist Checklists are integrated into error reduction strategies and healthcare team communication efforts worldwide but implementation and impact of the tool varies …

9030. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43354/psn-pdf
      July 16, 2014 - Weaving a healthcare tapestry of safety and communication. July 16, 2014 Hay J, Collin S, Koruth S. Weaving a healthcare tapestry of safety and communication. Nurs Manage. 2014;45(7):40-6. doi:10.1097/01.NUMA.0000451035.84587.7d. https://psnet.ahrq.gov/issue/weaving-healthcare-tapestry-safety-and-communication Th…

9031. 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…

9032. 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…

9033. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41931/psn-pdf
      December 19, 2012 - Preventing wrong-site surgery in Minnesota: a 5-year journey. December 19, 2012 Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34. https://psnet.ahrq.gov/issue/preventing-wrong-site-surgery-minnesota-5-year-journey Discussing a 5-year effort to report, analyze, and red…

9034. 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…

9035. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836867/psn-pdf
      April 06, 2022 - Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence. April 6, 2022 Houston TX;  Baylor College of Medicine: 2022. https://psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence Assessment can identify the current state of a process or program to reveal ar…

9036. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73123/psn-pdf
      April 01, 2020 - Digital Healthcare Research. April 1, 2020 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/digital-healthcare-research An understanding of the impact that digital tools can have on clinical decision making, patient self-care, and health system improvement is still emerging. This website hi…

9037. 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…

9038. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44610/psn-pdf
      May 03, 2017 - International Prize in Resilient Health Care. May 3, 2017 The Australian Institute of Health Innovation. https://psnet.ahrq.gov/issue/international-prize-resilient-health-care Innovations in patient safety can drive improvement efforts. This award program seeks to recognize feasible and widely implementable strate…

9039. 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/…

9040. 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…