-
psnet.ahrq.gov/node/46492/psn-pdf
November 29, 2017 - Topics covered include prescription monitoring, cancer care, and medicolegal
concerns of pain medication
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psnet.ahrq.gov/node/34808/psn-pdf
February 18, 2011 - Results include the specific complications from surgical misadventures and the associated cost
estimations
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psnet.ahrq.gov/node/60265/psn-pdf
January 01, 2019 - Topics
covered include foundations to the specialty, quality improvement, patient and family partnerships
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psnet.ahrq.gov/node/60217/psn-pdf
January 01, 2012 - Initiatives include the Confidential Enquiries into Maternal and Infant Deaths program which produces
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - Pertinent facts include (i) a verbal direction was given by the fellow to the resident to order vasopressin … For a case such as this, other members of the team should include an ICU physician, as well as representatives … The process could include complete medication reconciliation and review at patient entry and exit into … doses by the team should happen every morning (perhaps twice daily in an ICU) on rounds and should include … In addition, smart systems could include admitting diagnoses and, by combining that with patient location
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psnet.ahrq.gov/web-mm/impact-communication-medication-errors
August 01, 2009 - Typical errors include prescribing the wrong medication, route, dose, or frequency. … potentially inappropriate medications as indicated by the Beers Criteria . 2 Contributing factors include … Root causes can include breakdowns in communication, patient and caregiver education, and accountability … Risk factors for unsuccessful handoffs include conflicting expectations between sender and receiver, … evidence-based strategies that healthcare providers can employ for engaging patients and caregivers include
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psnet.ahrq.gov/node/34638/psn-pdf
December 23, 2008 - These include professional, economic, and political models, which, the authors argue, fail to serve an
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psnet.ahrq.gov/node/74215/psn-pdf
October 25, 2011 - Recommendations for improving diagnosis of depression among Black patients include
improving the cultural
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psnet.ahrq.gov/node/39454/psn-pdf
October 04, 2017 - British psychologist James Reason’s insights into the nature of human error and systems theory, which
include
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psnet.ahrq.gov/node/34740/psn-pdf
November 29, 2017 - Examples include giving patients access to their medical records,
giving them “written and/or visual
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psnet.ahrq.gov/node/47229/psn-pdf
August 01, 2018 - provide recommendations to encourage a strong
system-level commitment to respect and dignity, which include
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psnet.ahrq.gov/node/46487/psn-pdf
May 16, 2018 - Areas of focus include cognition, leadership, and
safety culture.
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psnet.ahrq.gov/node/43200/psn-pdf
May 21, 2014 - Topics include discussions about a checklist to assess
quality activities during patient care, variation
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psnet.ahrq.gov/node/44604/psn-pdf
August 02, 2016 - Interviewees include Sidney Dekker, Erik
Hollnagel, René Amalberti, and Charles Vincent.
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psnet.ahrq.gov/node/44942/psn-pdf
September 29, 2017 - Key barriers
to utilizing electronic health record data to inform improvement work include restricted
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psnet.ahrq.gov/node/46152/psn-pdf
May 31, 2017 - Unlike a prior study, researchers did not include patient perspectives in their
analysis, which may
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psnet.ahrq.gov/node/43943/psn-pdf
December 04, 2015 - Companion materials available include an analysis exploring equality considerations
and a table revealing
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psnet.ahrq.gov/node/47024/psn-pdf
November 28, 2018 - Recommendations to enhance safety include review of
medication labeling to select appropriate medicines
-
psnet.ahrq.gov/node/46719/psn-pdf
December 20, 2017 - Tactics suggested
that could facilitate improvement include participation in safety huddles and raising
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psnet.ahrq.gov/node/47205/psn-pdf
July 25, 2018 - Topics include organizational support for a team
environment, teamwork as a fall-reduction strategy,