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Showing results for "incident".

  1. Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. | PSNet

    psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems-months-shutdown-then
    July 18, 2018 - Newspaper/Magazine Article Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. Citation Text: Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. Massey W, Keith …

  2. Medicines-related harm in the elderly post-hospital discharge. | PSNet

    psnet.ahrq.gov/issue/medicines-related-harm-elderly-post-hospital-discharge
    February 07, 2024 - Commentary Medicines-related harm in the elderly post-hospital discharge. Citation Text: Medicines-related harm in the elderly post-hospital discharge. Cheong V-L, Tomlinson J, Khan S, et al. Prescriber. 2019;30:29-34. Copy Citation Save Save to your library …

  3. Nonfatal, unintentional medication exposures among young children—United States, 2001–2003. | PSNet

    psnet.ahrq.gov/issue/nonfatal-unintentional-medication-exposures-among-young-children-united-states-2001-2003
    February 27, 2019 - Government Resource Nonfatal, unintentional medication exposures among young children—United States, 2001–2003. Citation Text: Prevention C for DC and. Nonfatal, unintentional medication exposures among young children--United States, 2001-2003. MMWR Morb Mortal Wkly Rep. 2006;55(1):1-5…

  4. Recognizing the importance of whistleblowers in healthcare. | PSNet

    psnet.ahrq.gov/issue/recognizing-importance-whistleblowers-healthcare
    June 24, 2009 - Commentary Recognizing the importance of whistleblowers in healthcare. Citation Text: O'Neill N. Recognizing the importance of whistleblowers in healthcare. Nursing (Brux). 2021;51(4):54-56. doi:10.1097/01.nurse.0000736912.14380.65. Copy Citation Format: DOI Google Scholar …

  5. Handoff Communication Tools. | PSNet

    psnet.ahrq.gov/issue/handoff-communication-tools
    May 25, 2022 - Government Resource Handoff Communication Tools. Citation Text: Handoff Communication Tools. Landrigan CP, Lyons A, Gannon P, et al. FIRST Do No Harm. December 2012;1-8. Copy Citation Save Save to your library Print Download PDF Share Fa…

  6. Patient Safety Investigation report into services at University Hospital Galway (UHG) and as reflected in the care provided to Savita Halappanavar. | PSNet

    psnet.ahrq.gov/issue/patient-safety-investigation-report-services-university-hospital-galway-uhg-and-reflected
    June 14, 2017 - Book/Report Patient Safety Investigation report into services at University Hospital Galway (UHG) and as reflected in the care provided to Savita Halappanavar. Citation Text: Patient Safety Investigation report into services at University Hospital Galway (UHG) and as reflected in the ca…

  7. Improving the usability of intravenous medication labels to support safe medication delivery. | PSNet

    psnet.ahrq.gov/issue/improving-usability-intravenous-medication-labels-support-safe-medication-delivery
    September 26, 2016 - Study Improving the usability of intravenous medication labels to support safe medication delivery. Citation Text: Bauer DT, Guerlain S. Improving the usability of intravenous medication labels to support safe medication delivery. International journal of industrial ergonomics. 2011;41…

  8. Building social capital in healthcare organizations: thinking ecologically for safer care. | PSNet

    psnet.ahrq.gov/issue/building-social-capital-healthcare-organizations-thinking-ecologically-safer-care
    June 23, 2009 - Commentary Building social capital in healthcare organizations: thinking ecologically for safer care. Citation Text: Hofmeyer A, Marck PB. Building social capital in healthcare organizations: thinking ecologically for safer care. Nurs Outlook. 2008;56(4):145-151.e2. doi:10.1016/j.outlo…

  9. The public has been forgiving. But hospitals got some things wrong. | PSNet

    psnet.ahrq.gov/issue/public-has-been-forgiving-hospitals-got-some-things-wrong
    April 03, 2019 - Newspaper/Magazine Article The public has been forgiving. But hospitals got some things wrong. Citation Text: Ofri D. The public has been forgiving. But hospitals got some things wrong. New York Times. 2020; May 21. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML…

  10. Reduction in pediatric identification band errors: a quality collaborative. | PSNet

    psnet.ahrq.gov/issue/reduction-pediatric-identification-band-errors-quality-collaborative
    March 14, 2022 - Study Reduction in pediatric identification band errors: a quality collaborative. Citation Text: Phillips SC, Saysana M, Worley S, et al. Reduction in pediatric identification band errors: a quality collaborative. Pediatrics. 2012;129(6):e1587-93. doi:10.1542/peds.2011-1911. Copy Cit…

  11. Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts? | PSNet

    psnet.ahrq.gov/issue/subtherapeutic-heparin-infusions-your-organization-risk-bypassing-soft-low-dose-alerts
    November 18, 2020 - Newspaper/Magazine Article Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts? Citation Text: Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts? ISMP Medication Safety Alert! Acute Care Edition. …

  12. Why your TeamSTEPPS program may not be working. | PSNet

    psnet.ahrq.gov/issue/why-your-teamstepps-program-may-not-be-working
    February 14, 2024 - Commentary Why your TeamSTEPPS program may not be working. Citation Text: Clapper TC, Ng GM. Why Your TeamSTEPPS™ Program May Not Be Working. Clin Simul Nurs. 2012;9(8). doi:10.1016/j.ecns.2012.03.007. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote …

  13. Impact of a standard medication chart on prescribing errors: a before-and-after audit. | PSNet

    psnet.ahrq.gov/issue/impact-standard-medication-chart-prescribing-errors-and-after-audit
    May 02, 2012 - Study Impact of a standard medication chart on prescribing errors: a before-and-after audit. Citation Text: Coombes ID, Stowasser DA, Reid C, et al. Impact of a standard medication chart on prescribing errors: a before-and-after audit. Qual Saf Health Care. 2009;18(6):478-85. doi:10.11…

  14. Anatomy of a medical device recall: how defective products can slip through an outdated system. | PSNet

    psnet.ahrq.gov/issue/anatomy-medical-device-recall-how-defective-products-can-slip-through-outdated-system
    December 03, 2014 - Newspaper/Magazine Article Anatomy of a medical device recall: how defective products can slip through an outdated system. Citation Text: Anatomy of a medical device recall: how defective products can slip through an outdated system. Zipp R. Medical Tech Dive. October 18, 2021. Copy …

  15. Life after death: the aftermath of perioperative catastrophes. | PSNet

    psnet.ahrq.gov/issue/life-after-death-aftermath-perioperative-catastrophes
    March 29, 2012 - Review Life after death: the aftermath of perioperative catastrophes. Citation Text: Gazoni FM, Durieux ME, Wells L. Life after death: the aftermath of perioperative catastrophes. Anesth Analg. 2008;107(2):591-600. doi:10.1213/ane.0b013e31817a9c77. Copy Citation Format: D…

  16. Eight-year experience with a neurosurgical checklist. | PSNet

    psnet.ahrq.gov/issue/eight-year-experience-neurosurgical-checklist
    September 27, 2023 - Study Eight-year experience with a neurosurgical checklist. Citation Text: Lyons MK. Eight-year experience with a neurosurgical checklist. Am J Med Qual. 2010;25(4):285-8. doi:10.1177/1062860610363305. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML …

  17. Side errors in neurosurgery. | PSNet

    psnet.ahrq.gov/issue/side-errors-neurosurgery
    November 17, 2010 - Study Side errors in neurosurgery. Citation Text: Mitchell P, Nicholson CL, Jenkins A. Side errors in neurosurgery. Acta Neurochir (Wien). 2006;148(12):1289-92; discussion 1292. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…

  18. Techniques to improve patient safety in hospitals: what nurse administrators need to know. | PSNet

    psnet.ahrq.gov/issue/techniques-improve-patient-safety-hospitals-what-nurse-administrators-need-know
    December 22, 2008 - Review Techniques to improve patient safety in hospitals: what nurse administrators need to know. Citation Text: Fagan MJ. Techniques to improve patient safety in hospitals: what nurse administrators need to know. J Nurs Adm. 2012;42(9):426-430. doi:10.1097/NNA.0b013e3182664df5. Copy…

  19. Lessons from the war on cancer: the need for basic research on safety. | PSNet

    psnet.ahrq.gov/issue/lessons-war-cancer-need-basic-research-safety
    July 14, 2010 - Commentary Lessons from the war on cancer: the need for basic research on safety. Citation Text: Lessons from the war on cancer: the need for basic research on safety. Cook RI. J Patient Saf. 2005.1(1):7-8 Copy Citation Save Save to your library Print Do…

  20. Medication errors in older people with mental health problems: a review. | PSNet

    psnet.ahrq.gov/issue/medication-errors-older-people-mental-health-problems-review
    April 27, 2022 - Review Medication errors in older people with mental health problems: a review. Citation Text: doi:10.1002/gps.1943. Copy Citation Format: DOI BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation Save Save to y…
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