-
psnet.ahrq.gov/node/45789/psn-pdf
January 11, 2017 - Areas of concern identified by the investigation include a lack
of available data on the patient outcomes
-
psnet.ahrq.gov/node/44270/psn-pdf
July 01, 2015 - Lessons learned include the
value of engaging leadership, utilizing debriefing as a learning mechanism
-
psnet.ahrq.gov/node/46081/psn-pdf
April 19, 2017 - Strategies discussed include reducing variation on
measures collected and developing a culture of reporting
-
psnet.ahrq.gov/node/35193/psn-pdf
July 10, 2008 - These include system-related problems such as inefficient processes and cognitive problems such
as failure
-
psnet.ahrq.gov/node/42925/psn-pdf
February 05, 2014 - Design interventions
described include air filtration systems, decontamination of water sources, and
-
psnet.ahrq.gov/node/34659/psn-pdf
April 07, 2010 - These mistakes include not establishing a
great enough sense of urgency, not creating a powerful enough
-
psnet.ahrq.gov/node/47246/psn-pdf
September 19, 2018 - Strategies to enhance teamwork and consequently clinician well-being include improvements in workflow
-
psnet.ahrq.gov/node/47827/psn-pdf
February 27, 2019 - Topics covered include usability, implementation, interoperability, and policy.
-
psnet.ahrq.gov/node/43827/psn-pdf
January 14, 2015 - for patients and
families to build relationships and enable partnerships to help ensure safe care include
-
psnet.ahrq.gov/node/35228/psn-pdf
March 04, 2011 - Results include examination of current recommendations and data that
address those consensus-driven
-
psnet.ahrq.gov/node/35415/psn-pdf
December 21, 2008 - Topics covered through the series include leadership, culture, performance
improvement, information
-
psnet.ahrq.gov/node/46352/psn-pdf
October 15, 2018 - Topics covered include high reliability, teamwork, communication, and patient-centered culture.
-
psnet.ahrq.gov/node/44785/psn-pdf
January 27, 2016 - Highlighted recommendations include strategies to assess processes, identify best practices,
and engage
-
psnet.ahrq.gov/node/45318/psn-pdf
September 28, 2016 - The author proposes several tactics to
promote safe medication practices by parents which include picture-based
-
psnet.ahrq.gov/node/44386/psn-pdf
August 12, 2015 - using-simulation-improve-systems
Safety approaches from aviation that can be applied to health care include
-
psnet.ahrq.gov/node/44082/psn-pdf
April 22, 2015 - impact-including-readmissions-qualifying-events-patient-safety-indicators
The AHRQ Patient Safety Indicators (PSIs) do not include
-
psnet.ahrq.gov/node/43030/psn-pdf
March 26, 2014 - Tips include
establishing protocols for commonly used vaccines, requiring periodic training for staff
-
psnet.ahrq.gov/node/45756/psn-pdf
December 21, 2016 - Recommendations to reduce risks include
communicating during transitions, safe storage, and immediate
-
psnet.ahrq.gov/node/46931/psn-pdf
January 15, 2019 - Specific tactics discussed include proactive problem identification, medication
reconciliation, high-alert
-
psnet.ahrq.gov/node/43449/psn-pdf
September 03, 2014 - Some of the most promising interventions thus
far include smart pumps and computerized provider order