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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - administered, and if so, which drug.( Table 2 ) ( 1 ) The most common drugs that may lead to apnea include … Other interventions include discontinuation of anesthetics, determination of arterial blood gases, and … at least partially related to anesthesia, but those estimates are based on circumstantial data and include … System checks that could be implemented here to avoid inadvertent drug swaps include color-coded labeling … In addition, his commentary does not include information regarding investigational or off-label use of
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psnet.ahrq.gov/node/836812/psn-pdf
March 30, 2022 - Tools covered in this primer include incident reporting systems, Root
Cause Analysis (RCA), and Failure … Barriers to incident reporting include an organizational culture of
blame, health care staff's fear … is wide variation in how RCA is employed in organizations to
improve patient safety, common steps include
-
psnet.ahrq.gov/node/46105/psn-pdf
May 01, 2022 - Elements discussed include error reduction, leadership engagement, and safe working environment..
-
psnet.ahrq.gov/node/72861/psn-pdf
March 17, 2021 - recommends several strategies for gaining patient trust in the system to keep them safe from
exposure which include
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psnet.ahrq.gov/node/855002/psn-pdf
November 01, 2023 - Recommendations for improvement include examining electronic health record alerts, assigning
one prescriber
-
psnet.ahrq.gov/node/764411/psn-pdf
March 02, 2022 - tracking hospital-acquired COVID-19 infections and reasons that
control efforts may be lagging, which include
-
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/50782/psn-pdf
January 08, 2020 - Lessons include (1) focusing on systems-level factors, (2) institutional and leadership commitment
to
-
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/74248/psn-pdf
January 12, 2022 - Problems identified include poor leadership and teamwork, as well as learning and cross-
service collaboration
-
psnet.ahrq.gov/node/72608/psn-pdf
December 23, 2020 - Recommendations for improvement include an emphasis on
harm monitoring and incident reporting.
-
psnet.ahrq.gov/node/46243/psn-pdf
June 05, 2019 - Targeted areas of improvement include safety culture, teamwork skills, and partnering with
patients.
-
psnet.ahrq.gov/node/72585/psn-pdf
December 16, 2020 - Barriers
inherent to a universal testing strategy include operational challenges, patient testing volume
-
psnet.ahrq.gov/node/40644/psn-pdf
October 04, 2020 - Topics covered include speaking up, central line
infection prevention, and business case development
-
psnet.ahrq.gov/node/50644/psn-pdf
November 06, 2019 - Strategies presented during testimony to remedy these situations include improving employee
background
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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/74846/psn-pdf
February 16, 2022 - Areas of
focus for improvement include use of prescribing technology, and the double-check as an error
-
psnet.ahrq.gov/node/49645/psn-pdf
February 01, 2012 - intended to replace writing
out, faxing, or calling in prescriptions, and its many proposed benefits include … Three prescription
fields commonly requiring manual manipulation include medication name, quantity, … Other recommendations include providing
additional physician training and developing best practices … care summaries at transitions of care as a requirement for meaningful use
incentives should extend to include … In addition, the commentary does not include
information regarding investigational or off-label use
-
psnet.ahrq.gov/node/49549/psn-pdf
December 06, 2007 - These protocols should include assessment and
prevention procedures to reduce the risk of harm for patients … Such preventive
measures may include placing the patient on an observation protocol (special precautions … Such a protocol may include locating the patient close to the
desk, placing an electronic monitoring … Additional precautions
common in mental health and rehabilitation facilities include automatic door … In addition, the commentary does not include
information regarding investigational or off-label use
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psnet.ahrq.gov/issue/increasing-rate-detection-wrong-patient-radiographs-use-photographs-obtained-time-radiography
June 13, 2015 - November 4, 2015
Improvement in detection of wrong-patient errors when radiologists include … June 21, 2016
Improvement in detection of wrong-patient errors when radiologists include