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psnet.ahrq.gov/node/72711/psn-pdf
February 03, 2021 - Recommendations include revision of the NHS never events list,
identification of strong and systemic
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psnet.ahrq.gov/node/60669/psn-pdf
July 08, 2020 - The authors suggest that
prelicensure training include reinforcement of systems thinking principles
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psnet.ahrq.gov/node/47827/psn-pdf
February 27, 2019 - Topics covered include usability, implementation, interoperability, and policy.
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psnet.ahrq.gov/node/50761/psn-pdf
December 18, 2019 - Initial insights
discussed include the lack of a safety culture at the Trust Hospital facilitating the
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psnet.ahrq.gov/node/60020/psn-pdf
March 04, 2020 - Next steps for platform development and implementation
include creating capability for personalized
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psnet.ahrq.gov/node/72559/psn-pdf
December 09, 2020 - The 12 recommendations stemming from the investigation include
improvements in disclosure support, clinician
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psnet.ahrq.gov/node/849613/psn-pdf
May 31, 2023 - Recommendations to minimize
similar occurrences include removing the involved device from service and
-
psnet.ahrq.gov/node/837744/psn-pdf
July 27, 2022 - Recommendations to mitigate the potential for similar errors include risk assessment, hard stop use,
-
psnet.ahrq.gov/node/61054/psn-pdf
October 21, 2020 - These actions include proactive determination of metrics and a process for tracking
activities, use
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psnet.ahrq.gov/node/73147/psn-pdf
April 14, 2021 - This
news story discusses a patient’s experience with common contributors to delay that include Insufficient
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psnet.ahrq.gov/node/49743/psn-pdf
September 01, 2015 - In most cases with warfarin, patients are provided an identification card, which can
include the anticipated … duration of therapy and might be expanded to include DAPT. … pharmacist receives a new prescription for a medication like
clopidogrel, there is another opportunity to include … Medication reconciliation should be accomplished at each clinic or office visit and should include a
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.326_slideshow.ppt
June 01, 2014 - patients to wander while in an acute care hospital
From experience, common reasons patients wander include … beyond their assigned ward or unit without assistance place themselves at risk for complications that include … Publishing; 2002:Sec 27-62.
13
Reducing the Risk
Options for reducing the risk of patient wandering include … physical security measures that reduce the potential for elopement and reduce risk to patients
These might include
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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
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psnet.ahrq.gov/issue/evaluation-near-miss-wrong-patient-events-radiology-reports
June 13, 2015 - June 13, 2015
Improvement in detection of wrong-patient errors when radiologists include … September 24, 2016
Improvement in detection of wrong-patient errors when radiologists include
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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/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
September 09, 2013 - Specific prophylactic approaches to reduce immunosuppression-related adverse effects include treatments … The most effective care transitions interventions span the entire transitional period and include elements … Common adverse effects with longer-term corticosteroid exposure include Cushingoid appearance, osteoporosis … The most common errors made in prescribing corticosteroids include issues with tapering, drug choice, … In addition, the commentary does not include information regarding investigational or off-label use of
-
psnet.ahrq.gov/node/47738/psn-pdf
February 06, 2019 - Recommended approaches include avoidance of error-prone abbreviations, use
of Tall Man lettering, and
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psnet.ahrq.gov/node/60932/psn-pdf
January 01, 2021 - Recommendations
include avoidance of environmental hazards, medication monitoring, control of firearms
-
psnet.ahrq.gov/node/47913/psn-pdf
April 10, 2019 - This quality
improvement study sought to standardize paging communication to include six critical elements
-
psnet.ahrq.gov/node/60929/psn-pdf
September 16, 2020 - Its areas of focus include culture, leadership, and governance,
patient and family engagement, workforce