-
psnet.ahrq.gov/node/847057/psn-pdf
April 05, 2023 - Recommended areas of focus include reducing emphasis on the “Five Rights” to address system
problems
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psnet.ahrq.gov/node/50874/psn-pdf
February 05, 2020 - This report examines the use of the
WHO Surgical Safety Checklist and barriers to its uptake which include
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psnet.ahrq.gov/node/764410/psn-pdf
March 02, 2022 - This article shares five
strategies to enhance individual clinician diagnostic practices which include
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psnet.ahrq.gov/node/47821/psn-pdf
May 22, 2019 - Topics covered in the communications include look-alike and sound-alike drugs, patient safety
audits
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psnet.ahrq.gov/node/849138/psn-pdf
May 17, 2023 - Themes identified as contributing to the problems include lack of
information sharing, inconsistent
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psnet.ahrq.gov/node/50722/psn-pdf
December 04, 2019 - Topics covered include the
ineffectiveness of current measures and lack of leadership commitment to
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psnet.ahrq.gov/web-mm/specimen-almost-lost
September 21, 2022 - This may include when specimens come from unusual locations, rare tests are ordered, or special care … Other risk factors for specimen loss or misprocessing include reliance on individuals to do the right … should be considered, including those that may be costly, such as an overhaul of the EHR and LIS to include … accessioned manually, risks associated with human error remain.( 6 ) Less costly systems solutions include … specimen time outs, which can be embedded into surgical or clinical checklists.( 7 ) The time out may include
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psnet.ahrq.gov/node/72587/psn-pdf
December 23, 2020 - physical movement of
critically ill patients is fraught with potential safety risks.1-4 These risks include … This team
communication should, for example, include specifically asking “What might go wrong and what … Transport
teams should include personnel with expertise in preventing perturbations in physiological … This process should include
consideration of any available bedside alternatives. … These activities should be supported by
clear institutional guidelines and/or protocols that include
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psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - risk of mistakes.4
Preventing medication errors in anesthesia demands a concerted effort that may include … designed around ease of use,
speed of use and functionality, standardization, technical support to include … Ensuring a safety culture starts from
the time a provider joins the department and should include education … safety culture, error prevention and recovery programs are well developed, updated regularly,
and include … Include simulation training in clinical education
Simulation is an interactive educational tool that
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psnet.ahrq.gov/node/858325/psn-pdf
December 13, 2023 - Improvement strategies
discussed include patient education, practitioner coaching and interpreter services
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psnet.ahrq.gov/node/46105/psn-pdf
May 01, 2022 - Elements discussed include error reduction, leadership engagement, and safe working environment..
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psnet.ahrq.gov/node/50782/psn-pdf
January 08, 2020 - Lessons include (1) focusing on systems-level factors, (2) institutional and leadership commitment
to
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psnet.ahrq.gov/node/74846/psn-pdf
February 16, 2022 - Areas of
focus for improvement include use of prescribing technology, and the double-check as an error
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psnet.ahrq.gov/node/40644/psn-pdf
October 04, 2020 - Topics covered include speaking up, central line
infection prevention, and business case development
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psnet.ahrq.gov/node/72585/psn-pdf
December 16, 2020 - Barriers
inherent to a universal testing strategy include operational challenges, patient testing volume
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psnet.ahrq.gov/node/841200/psn-pdf
December 07, 2022 - It shares improvement recommendations that
include best practice adherence, standardization, monitoring
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psnet.ahrq.gov/node/74248/psn-pdf
January 12, 2022 - Problems identified include poor leadership and teamwork, as well as learning and cross-
service collaboration
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psnet.ahrq.gov/node/72583/psn-pdf
December 16, 2020 - Recommendations
for safety include enhanced screening to ensure masks are safe for the exam environment
-
psnet.ahrq.gov/node/843323/psn-pdf
February 01, 2023 - Department of
Health and Human Services Office of the Inspector General include heightened evaluation
-
psnet.ahrq.gov/node/855002/psn-pdf
November 01, 2023 - Recommendations for improvement include examining electronic health record alerts, assigning
one prescriber