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psnet.ahrq.gov/issue/defining-critical-role-nurses-diagnostic-error-prevention-conceptual-framework-and-call
October 28, 2020 - suggest improvements in health care culture is required to implement the recommended changes, which include
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psnet.ahrq.gov/issue/clinical-and-economic-impact-medication-reconciliation-cancer-patients-systematic-review
January 27, 2019 - While the majority of studies did not include a contemporaneous comparison group, they did report that
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psnet.ahrq.gov/issue/systematic-review-impact-health-information-technology-quality-efficiency-and-costs-medical
March 30, 2022 - The benefits reported include improved adherence to guideline-based care, enhanced surveillance and monitoring
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psnet.ahrq.gov/issue/debrief-it-all-tool-inclusion-safety-ii
June 08, 2022 - pilot-tested a debriefing tool to broaden the traditional focus of debriefs from “what went wrong ” to also include
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psnet.ahrq.gov/issue/new-graduate-registered-nurses-risk-mitigation-strategies-ensure-safety-and-successful
September 28, 2022 - Recommendations for improving the transition to practice include innovative academic-clinical partnerships
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psnet.ahrq.gov/issue/fda-alerts-patients-and-health-care-professionals-epipen-auto-injector-errors-related-device
April 07, 2019 - Recommendations to address the problem include patient review of instructions and practice with the device
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psnet.ahrq.gov/issue/abrupt-expansion-ambulatory-telemedicine-implications-patient-safety
July 13, 2022 - Recommendations to further understand the impact of telemedicine on patient safety include: systematically
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psnet.ahrq.gov/issue/diagnostic-accuracy-physician-staffed-emergency-medical-teams-retrospective-observational
December 22, 2021 - In Germany, prehospital emergency response teams include physicians, but little is known about their
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psnet.ahrq.gov/issue/rates-serious-surgical-errors-california-and-plans-prevent-recurrence
March 09, 2022 - Recommended strategies to reduce and prevent never events include proper use of intraoperative checklists
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psnet.ahrq.gov/issue/factors-associated-workarounds-barcode-assisted-medication-administration-hospitals
January 23, 2019 - Potential risk factors identified include the timing of medication rounds, the route of administration
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psnet.ahrq.gov/issue/perfect-storm-exam-medical-error-and-factors-contributing-its-possible-escalation
October 20, 2021 - Failures include differences in recording electronic health record notes and communication between
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psnet.ahrq.gov/issue/patient-and-family-engagement-catheter-associated-urinary-tract-infection-cauti-prevention
February 07, 2022 - Interventions to prevent catheter-associated urinary tract infections (CAUTI) can include multiple components
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psnet.ahrq.gov/issue/developing-safer-dx-checklist-ten-safety-recommendations-health-care-organizations-address
June 22, 2022 - Priority practices include promoting speaking up behaviors through a just culture and psychologically
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psnet.ahrq.gov/issue/implementing-high-reliability-organization-principles-practice-rapid-evidence-review
October 21, 2020 - Future research should include concurrent control groups to minimize bias and focus on whether certain
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psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-chemotherapy-preparation-process
March 09, 2022 - Potential approaches to reduce these failure modes include updating the Standard Operating Procedures
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psnet.ahrq.gov/issue/misdiagnosis-mistreatment-and-harm-when-medical-care-ignores-social-forces
November 16, 2022 - The authors argue that medical education at all levels should include training in social medicine frameworks
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psnet.ahrq.gov/issue/omissions-care-nursing-home-settings-narrative-review
November 18, 2020 - agreement that delays or failure of care constitutes an omission of care, but differing views on whether to include
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psnet.ahrq.gov/issue/race-and-clinical-diagnosis-depression-new-primary-care-patients
October 21, 2020 - Recommendations for improving diagnosis of depression among Black patients include improving the cultural
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psnet.ahrq.gov/node/33587/psn-pdf
June 15, 2024 - The structural factors contributing to missed nursing care
include:
labor resources: number and types … The more routine consequences of missed nursing care can include delayed or omitted medications or
treatments … Evaluation of organizational nurse staffing plans should include not
just the average needs of nursing
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psnet.ahrq.gov/issue/human-contribution-unsafe-acts-accidents-and-heroic-recoveries
August 06, 2016 - British psychologist James Reason’s insights into the nature of human error and systems theory, which include