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Showing results for "incidents".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45001/psn-pdf
    June 01, 2016 - Relationship between job burnout, psychosocial factors and health care–associated infections in critical care units. June 1, 2016 Galletta M, Portoghese I, D'Aloja E, et al. Relationship between job burnout, psychosocial factors and health care-associated infections in critical care units. Intensive Crit Care Nurs…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37699/psn-pdf
    February 22, 2011 - The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: a systematic review. February 22, 2011 Wolfstadt JI, Gurwitz JH, Field T, et al. The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46978/psn-pdf
    April 04, 2018 - Using the patient safety huddle as a tool for high reliability. April 4, 2018 Brass SD, Olney G, Glimp R, et al. Using the Patient Safety Huddle as a Tool for High Reliability. Jt Comm J Qual Patient Saf. 2018;44(4):219-226. doi:10.1016/j.jcjq.2017.10.004. https://psnet.ahrq.gov/issue/using-patient-safety-huddle-t…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851913/psn-pdf
    August 02, 2023 - Meta-analysis of medication administration errors in African hospitals. August 2, 2023 Alemu W, Cimiotti JP. Meta-analysis of medication administration errors in African hospitals. J Healthc Qual. 2023;45(4):233-241. doi:10.1097/jhq.0000000000000396. https://psnet.ahrq.gov/issue/meta-analysis-medication-administra…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60648/psn-pdf
    July 01, 2020 - Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives. July 1, 2020 Osterholm MT, Olshaker M. Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives. Foreign Affairs. 2020;99:4. https://psnet.ahrq.gov/issue/chronicle-pan…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73325/psn-pdf
    May 26, 2021 - Communication of preclinical emergency teams in critical situations: a nationwide study. May 26, 2021 Zimmer M, Czarniecki DM, Sahm S. Communication of preclinical emergency teams in critical situations: a nationwide study. PLoS One. 2021;16(5):e0250932. doi:10.1371/journal.pone.0250932. https://psnet.ahrq.gov/iss…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38333/psn-pdf
    January 14, 2009 - Adverse Events in Hospitals: Overview of Key Issues. January 14, 2009 Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470. https://psnet.ahrq.gov/issue/adverse-events-hospitals-overview-key-issues The Tax Relief and Hea…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837041/psn-pdf
    May 04, 2022 - APSF endorsed statement on revising recommendations for patient monitoring during anesthesia. May 4, 2022 The APSF Committee on Technology. APSF Newsletter. 2022;37(1):7–8. https://psnet.ahrq.gov/issue/apsf-endorsed-statement-revising-recommendations-patient-monitoring-during- anesthesia Variation across sta…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43142/psn-pdf
    June 15, 2014 - Development and sustainability of an inpatient-to- outpatient discharge handoff tool: a quality improvement project. June 15, 2014 Moy NY, Lee SJ, Chan T, et al. Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project. Jt Comm J Qual Patient Saf. 2014;40(5…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38101/psn-pdf
    December 17, 2009 - The unintended consequences of computerized provider order entry: findings from a mixed methods exploration. December 17, 2009 Ash JS, Sittig DF, Dykstra RH, et al. The unintended consequences of computerized provider order entry: Findings from a mixed methods exploration. Int J Med Inform. 2008;78. doi:10.1016/j.i…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47206/psn-pdf
    January 01, 2021 - Understanding the types and effects of clinical interruptions and distractions recorded in a multihospital patient safety reporting system. October 17, 2018 Kellogg KM, Puthumana JS, Fong A, et al. Understanding the Types and Effects of Clinical Interruptions and Distractions Recorded in a Multihospital Patient Sa…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60038/psn-pdf
    March 11, 2020 - Errors associated with oxytocin use: a multi-organization analysis by ISMP and ISMP Canada. March 11, 2020 ISMP Medication Safety Alert! Acute care edition. February 13, 2020;25(3):1-6. https://psnet.ahrq.gov/issue/errors-associated-oxytocin-use-multi-organization-analysis-ismp-and-ismp- canada Errors in IV …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844748/psn-pdf
    February 15, 2023 - 'They were his best shot. And they failed to help’: why did EMS workers neglect Tyre Nichols? February 15, 2023 Renault M. STAT. February 6, 2023. https://psnet.ahrq.gov/issue/they-were-his-best-shot-and-they-failed-help-why-did-ems-workers-neglect- tyre-nichols Emergent care situations are vulnerable to a range …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48102/psn-pdf
    August 07, 2019 - The unmeasured quality metric: burn out and the second victim syndrome in healthcare. August 7, 2019 Heiss K, Clifton M. The unmeasured quality metric: Burn out and the second victim syndrome in healthcare. Semin Pediatr Surg. 2019;28(3):189-194. doi:10.1053/j.sempedsurg.2019.04.011. https://psnet.ahrq.gov/issue/u…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73328/psn-pdf
    May 26, 2021 - Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia. May 26, 2021 Washington DC:  Department of Veterans Affairs. Office of Inspector General; May 11, 2021. Report No. 20-03593-140. https://psnet.ahrq.gov/issue/care-and-oversigh…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846750/psn-pdf
    March 29, 2023 - Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame. March 29, 2023 Brattebø G, Flaatten HK. Errors in medicine: punishment versus learning medical adverse events revisited – expanding the frame. Curr Opin Anaesthesiol. 2023;36(2):240-245. doi:10.1097/aco.0000000000…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45009/psn-pdf
    March 30, 2016 - Fatal mistakes. March 30, 2016 Kliff S. Vox Media. March 15, 2016. https://psnet.ahrq.gov/issue/fatal-mistakes Health professionals involved in medical errors experience psychological stress, which can have serious consequences if they are unable to cope with their mistake. Reporting on the second victim phenomeno…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837065/psn-pdf
    May 11, 2022 - Fast tracking in cardiac surgery: is it safe? May 11, 2022 MacLeod JB, D’Souza K, Aguiar C, et al. Fast tracking in cardiac surgery: is it safe? J Cardiothorac Surg. 2022;17(1):69. doi:10.1186/s13019-022-01815-9. https://psnet.ahrq.gov/issue/fast-tracking-cardiac-surgery-it-safe Post-operative complications can le…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44239/psn-pdf
    September 29, 2017 - When medical care leads to harm—difficulty finding words: a teachable moment. September 29, 2017 Chamberlain E, DiVeronica M, Segura R. When medical care leads to harm- difficulty finding words: a teachable moment. JAMA Intern Med. 2015;175(8):1271-1272. doi:10.1001/jamainternmed.2015.2334. https://psnet.ahrq.gov/…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46239/psn-pdf
    January 01, 2021 - Identifying high-alert medications in a university hospital by applying data from the medication error reporting system. August 16, 2017 Tyynismaa L, Honkala A, Airaksinen M, et al. Identifying High-alert Medications in a University Hospital by Applying Data From the Medication Error Reporting System. J Patient Sa…
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