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Showing results for "incident".

  1. When things go wrong: how health care organizations deal with major failures. | PSNet

    psnet.ahrq.gov/issue/when-things-go-wrong-how-health-care-organizations-deal-major-failures
    March 13, 2013 - Commentary Classic When things go wrong: how health care organizations deal with major failures. Citation Text: Walshe K, Shortell SM. When things go wrong: how health care organizations deal with major failures. Health Aff (Millwood). 2004;23(3):103-11. Copy …

  2. Sleep deprivation, elective surgical procedures, and informed consent. | PSNet

    psnet.ahrq.gov/issue/sleep-deprivation-elective-surgical-procedures-and-informed-consent
    December 21, 2017 - Commentary Sleep deprivation, elective surgical procedures, and informed consent. Citation Text: Nurok M, Czeisler CA, Lehmann LS. Sleep deprivation, elective surgical procedures, and informed consent. N Engl J Med. 2010;363(27):2577-9. doi:10.1056/NEJMp1007901. Copy Citation For…

  3. Nursing student medication errors involving tubing and catheters: a descriptive study. | PSNet

    psnet.ahrq.gov/issue/nursing-student-medication-errors-involving-tubing-and-catheters-descriptive-study
    July 14, 2010 - Study Nursing student medication errors involving tubing and catheters: a descriptive study. Citation Text: Wolf ZR, Hicks RW, Altmiller G, et al. Nursing student medication errors involving tubing and catheters: A descriptive study. Nurse Educ Today. 2009;29(6). doi:10.1016/j.nedt.200…

  4. Emergency medical and health providers' perceptions of key issues in prehospital patient safety. | PSNet

    psnet.ahrq.gov/issue/emergency-medical-and-health-providers-perceptions-key-issues-prehospital-patient-safety
    January 11, 2017 - Study Emergency medical and health providers' perceptions of key issues in prehospital patient safety. Citation Text: Atack L, Maher J. Emergency medical and health providers' perceptions of key issues in prehospital patient safety. Prehosp Emerg Care. 2010;14(1):95-102. doi:10.3109/10…

  5. Survey results: smart pump data analytics pump metrics that should be monitored to improve safety. | PSNet

    psnet.ahrq.gov/issue/survey-results-smart-pump-data-analytics-pump-metrics-should-be-monitored-improve-safety
    August 08, 2018 - Newspaper/Magazine Article Survey results: smart pump data analytics pump metrics that should be monitored to improve safety. Citation Text: Survey results: smart pump data analytics pump metrics that should be monitored to improve safety. ISMP Medication Safety Alert! Acute care edition…

  6. Potentially inappropriate medications and adverse drug effects in elders in the ED. | PSNet

    psnet.ahrq.gov/issue/potentially-inappropriate-medications-and-adverse-drug-effects-elders-ed
    December 23, 2020 - Study Potentially inappropriate medications and adverse drug effects in elders in the ED. Citation Text: Nixdorff N, Hustey FM, Brady AK, et al. Potentially inappropriate medications and adverse drug effects in elders in the ED. Am J Emerg Med. 2008;26(6):697-700. doi:10.1016/j.ajem.20…

  7. Learning without borders: a review of the implementation of medical error reporting in Médecins Sans Frontières. | PSNet

    psnet.ahrq.gov/issue/learning-without-borders-review-implementation-medical-error-reporting-medecins-sans
    December 21, 2022 - Study Learning without borders: a review of the implementation of medical error reporting in Médecins Sans Frontières. Citation Text: Shanks L, Bil K, Fernhout J. Learning without Borders: A Review of the Implementation of Medical Error Reporting in Médecins Sans Frontières. PLoS One. 20…

  8. John M. Eisenberg Patient Safety Awards. Research: David W. Bates, MD, MSc, Brigham and Women's Hospital. | PSNet

    psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-awards-research-david-w-bates-md-msc-brigham-and-womens
    July 25, 2018 - Commentary John M. Eisenberg Patient Safety Awards. Research: David W. Bates, MD, MSc, Brigham and Women's Hospital. Citation Text: Bates DW. John M. Eisenberg Patient Safety Awards. Research: David W. Bates, MD, MSc, Brigham and Women's Hospital. Interview by Steven Berman. Jt Comm J Q…

  9. Achieving the 'perfect handoff' in patient transfers: building teamwork and trust. | PSNet

    psnet.ahrq.gov/issue/achieving-perfect-handoff-patient-transfers-building-teamwork-and-trust
    October 08, 2016 - Commentary Achieving the 'perfect handoff' in patient transfers: building teamwork and trust. Citation Text: Clarke D, Werestiuk K, Schoffner A, et al. Achieving the 'perfect handoff' in patient transfers: building teamwork and trust. J Nurs Manag. 2012;20(5):592-8. doi:10.1111/j.1365-…

  10. Simulation for operational readiness in a new freestanding emergency department: strategy and tactics. | PSNet

    psnet.ahrq.gov/issue/simulation-operational-readiness-new-freestanding-emergency-department-strategy-and-tactics
    August 20, 2018 - Study Simulation for operational readiness in a new freestanding emergency department: strategy and tactics. Citation Text: Kerner RL, Gallo K, Cassara M, et al. Simulation for Operational Readiness in a New Freestanding Emergency Department. Simul Healthc. 2016;11(5). doi:10.1097/sih.00…

  11. Using simulation to improve patient safety: dawn of a new era. | PSNet

    psnet.ahrq.gov/issue/using-simulation-improve-patient-safety-dawn-new-era
    October 29, 2017 - Commentary Using simulation to improve patient safety: dawn of a new era. Citation Text: Cheng A, Grant V, Auerbach M. Using simulation to improve patient safety: dawn of a new era. JAMA Pediatr. 2015;169(5):419-20. doi:10.1001/jamapediatrics.2014.3817. Copy Citation Format: …

  12. Medication errors—new approaches to prevention. | PSNet

    psnet.ahrq.gov/issue/medication-errors-new-approaches-prevention
    November 18, 2016 - Review Medication errors—new approaches to prevention. Citation Text: Merry A, Anderson BJ. Medication errors--new approaches to prevention. Paediatr Anaesth. 2011;21(7):743-53. doi:10.1111/j.1460-9592.2011.03589.x. Copy Citation Format: DOI Google Scholar PubMed BibTeX E…

  13. Actions Needed to Address Employee Misconduct Process and Ensure Accountability. | PSNet

    psnet.ahrq.gov/issue/actions-needed-address-employee-misconduct-process-and-ensure-accountability
    July 11, 2018 - Book/Report Actions Needed to Address Employee Misconduct Process and Ensure Accountability. Citation Text: Actions Needed to Address Employee Misconduct Process and Ensure Accountability. Washington, DC: United States Government Accountability Office; July 2018. Publication GAO-18-137. …

  14. A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy. | PSNet

    psnet.ahrq.gov/issue/method-prioritizing-interventions-following-root-cause-analysis-rca-lessons-philosophy
    March 11, 2015 - Commentary A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy. Citation Text: Boyd M. A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy. J Eval Clin Pract. 2015;21(3):461-9. doi:10.1111/j…

  15. Interorganizational complexity and organizational accident risk: a literature review. | PSNet

    psnet.ahrq.gov/issue/interorganizational-complexity-and-organizational-accident-risk-literature-review
    June 02, 2021 - Review Interorganizational complexity and organizational accident risk: a literature review. Citation Text: Milch V, Laumann K. Interorganizational complexity and organizational accident risk: A literature review. Safety Sci. 2015;82:9-17. doi:10.1016/j.ssci.2015.08.010. Copy Citation …

  16. An observational study of practice during transfer of patients from anaesthetic room to operating theatre. | PSNet

    psnet.ahrq.gov/issue/observational-study-practice-during-transfer-patients-anaesthetic-room-operating-theatre
    September 27, 2016 - Study An observational study of practice during transfer of patients from anaesthetic room to operating theatre. Citation Text: Broom MA, Slater J, Ure DS. An observational study of practice during transfer of patients from anaesthetic room to operating theatre. Anaesthesia. 2006;61(10…

  17. Interruptions and medication administration in critical care. | PSNet

    psnet.ahrq.gov/issue/interruptions-and-medication-administration-critical-care
    December 08, 2021 - Review Interruptions and medication administration in critical care. Citation Text: Bower R, Jackson C, Manning JC. Interruptions and medication administration in critical care. Nurs Crit Care. 2015;20(4):183-95. doi:10.1111/nicc.12185. Copy Citation Format: DOI Google Scho…

  18. Checking anaesthetic equipment 2012: Association of Anaesthetists of Great Britain and Ireland. | PSNet

    psnet.ahrq.gov/issue/checking-anaesthetic-equipment-2012-association-anaesthetists-great-britain-and-ireland
    August 04, 2021 - Organizational Policy/Guidelines Checking anaesthetic equipment 2012: Association of Anaesthetists of Great Britain and Ireland. Citation Text: Anderson E, Bythell V, Gemmell L, et al. Checking Anaesthetic Equipment 2012. Anaesthesia. 2012;67(6). doi:10.1111/j.1365-2044.2012.07163.x. …

  19. Antecedents of willingness to report medical treatment errors in health care organizations: a multilevel theoretical framework. | PSNet

    psnet.ahrq.gov/issue/antecedents-willingness-report-medical-treatment-errors-health-care-organizations-multilevel
    May 06, 2015 - Commentary Antecedents of willingness to report medical treatment errors in health care organizations: a multilevel theoretical framework. Citation Text: Naveh E, Katz-Navon T. Antecedents of willingness to report medical treatment errors in health care organizations: a multilevel theo…

  20. It is time to define antimicrobial never events. | PSNet

    psnet.ahrq.gov/issue/it-time-define-antimicrobial-never-events
    November 16, 2022 - Commentary It is time to define antimicrobial never events. Citation Text: Liu J, Kaye KS, Mercuro NJ, et al. It is time to define antimicrobial never events. Infect Control Hosp Epidemiol. 2019;40(2):206-207. doi:10.1017/ice.2018.313. Copy Citation Format: DOI Google Schol…
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