-
psnet.ahrq.gov/node/854897/psn-pdf
October 31, 2023 - The strategies employed in this study included implementing
a standardized protocol for medication administration
-
psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
February 21, 2024 - Implementing SBAR across a large multihospital health system.
-
psnet.ahrq.gov/web-mm/death-pca
January 06, 2017 - A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary
-
psnet.ahrq.gov/node/73642/psn-pdf
August 25, 2021 - Implementing interventions to address these
barriers, such as requiring multidisciplinary education
-
psnet.ahrq.gov/node/49552/psn-pdf
January 01, 2008 - Institutional efforts should focus on implementing curricula in medical errors at all levels of medical
-
psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - Institutions should support error disclosure both by providing communication skills training and by
implementing
-
psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - distractors, convoluted processes, and system misconfiguration. 2 Despite error reduction efforts through implementing
-
psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - Implementing ways to increase feedback will enhance quality and may minimize error.( 14 ) Especially
-
psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - December 14, 2022
Lessons learned in implementing a chronic opioid therapy management
-
psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
September 15, 2024 - applying these strategies prior to the outbreak of the pandemic to reduce threats to safe care, but implementing
-
psnet.ahrq.gov/node/60541/psn-pdf
May 01, 2013 - Targeted versus universal decolonization to prevent ICU
infection.
May 1, 2013
Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU
infection. N Engl J Med. 2013;368(24):2255-2265. doi:10.1056/nejmoa1207290.
https://psnet.ahrq.gov/issue/targeted-versus-universal-decoloni…
-
psnet.ahrq.gov/node/764399/psn-pdf
March 02, 2022 - Show me the money, I'll show you my complications:
impacts of incentivized incident self-reporting among
surgeons.
March 2, 2022
Cook-Richardson S, Addo A, Kim P, et al. Show me the money, I'll show you my complications: impacts of
incentivized incident self-reporting among surgeons. J Surg Res. 2022;274:136-144.
…
-
psnet.ahrq.gov/node/36186/psn-pdf
September 30, 2010 - Findings of the first consensus conference on medical
emergency teams.
September 30, 2010
DeVita MA, Bellomo R, Hillman KM, et al. Findings of the First Consensus Conference on Medical
Emergency Teams*. Crit Care Med. 2006;34(9). doi:10.1097/01.ccm.0000235743.38172.6e.
https://psnet.ahrq.gov/issue/findings-first-c…
-
psnet.ahrq.gov/node/37113/psn-pdf
March 24, 2011 - Mature rapid response system and potentially avoidable
cardiopulmonary arrests in hospital.
March 24, 2011
Galhotra S, DeVita MA, Simmons RL, et al. Mature rapid response system and potentially avoidable
cardiopulmonary arrests in hospital. Qual Saf Health Care. 2007;16(4):260-265.
https://psnet.ahrq.gov/issue/mat…
-
psnet.ahrq.gov/node/44350/psn-pdf
July 29, 2015 - Reporting and using near-miss events to improve patient
safety in diverse primary care practices: a collaborative
approach to learning from our mistakes.
July 29, 2015
Crane S, Sloane PD, Elder NC, et al. Reporting and Using Near-miss Events to Improve Patient Safety in
Diverse Primary Care Practices: A Collaborat…
-
psnet.ahrq.gov/node/837502/psn-pdf
June 22, 2022 - Toward safer opioid prescribing in HIV care (TOWER): a
mixed-methods, cluster-randomized trial.
June 22, 2022
Cedillo G, George MC, Deshpande R, et al. Toward safer opioid prescribing in HIV care (TOWER): a
mixed-methods, cluster-randomized trial. Addict Sci Clin Pract. 2022;17(1):28. doi:10.1186/s13722-022-
00311…
-
psnet.ahrq.gov/node/837023/psn-pdf
May 04, 2022 - Examining the effect of quality improvement initiatives on
decreasing racial disparities in maternal morbidity.
May 4, 2022
Davidson C, Denning S, Thorp K, et al. Examining the effect of quality improvement initiatives on
decreasing racial disparities in maternal morbidity. BMJ Qual Saf. 2022;31(9):670-678. doi:10.…
-
psnet.ahrq.gov/node/47880/psn-pdf
June 18, 2019 - A multidisciplinary model for reviewing severe maternal
morbidity cases and teaching residents patient safety
principles.
June 18, 2019
Ogunyemi D, Hage N, Kim SK, et al. A Multidisciplinary Model for Reviewing Severe Maternal Morbidity
Cases and Teaching Residents Patient Safety Principles. Jt Comm J Qual Patient…
-
psnet.ahrq.gov/node/851189/psn-pdf
July 05, 2023 - So many ways to be wrong: completeness and accuracy
in a prospective study of OR-to-ICU handoff
standardization.
July 5, 2023
Conn Busch J, Wu J, Anglade E, et al. So many ways to be wrong: completeness and accuracy in a
prospective study of OR-to-ICU handoff standardization. Jt Comm J Qual Patient Saf. 2023;49(8)…
-
psnet.ahrq.gov/node/851923/psn-pdf
August 02, 2023 - Patient, carer and family experiences of seeking redress
and reconciliation following a life-changing event:
systematic review of qualitative evidence.
August 2, 2023
Shaw L, Lawal HM, Briscoe S, et al. Patient, carer and family experiences of seeking redress and
reconciliation following a life?changing event: sys…