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psnet.ahrq.gov/web-mm/good-catch-operating-room
August 27, 2017 - Good Catch in the Operating Room
Citation Text:
Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Medication Mix-Up Leads to Patient Death
Citation Text:
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
January 31, 2024 - The Unhappy Patient Leaves Against Medical Advice.
Citation Text:
Nichols A. The Unhappy Patient Leaves Against Medical Advice.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - SPOTLIGHT CASE
The Other Side
Citation Text:
Vincent CA. The Other Side. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/complaints-safety-surveillance
May 05, 2021 - Complaints as Safety Surveillance
Citation Text:
Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - In Conversation with…David W. Bates, MD, MSc
May 1, 2008
In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
Editor's note: Dr. David Bates is a Professor at Harvard Medical School, Medical Director of Clinical and
Quality …
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psnet.ahrq.gov/node/33885/psn-pdf
August 01, 2019 - In Conversation With… Susan Smith, MD
August 1, 2019
In Conversation With… Susan Smith, MD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-susan-smith-md
Editor's note: Dr. Smith, a family medicine physician, is chief faculty practices officer for UCSF Health.
Over the past 3–4 years, the …
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psnet.ahrq.gov/node/33801/psn-pdf
February 01, 2016 - In Conversation With…Christine A. Sinsky, MD
February 1, 2016
In Conversation With…Christine A. Sinsky, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
Editor's note: Christine A. Sinsky, MD, is the Vice President for Professional Satisfaction at the American
Me…
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psnet.ahrq.gov/web-mm/more-treatment-better-care
August 11, 2021 - More Treatment—Better Care?
Citation Text:
Redberg R. More Treatment—Better Care?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
January 31, 2024 - This perspective includes the contribution of Dr. … Graber’s pioneering work on diagnostic error in 2005, which includes an identification of systemic problems … Clinical decision making is a complex process that includes a variety of factors. … Clinician-centered misdiagnosis is only a part of overall diagnostic safety; the NASEM definition also includes … guidance that scales to particular needs at the level of individual practitioner whose scope of work includes
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psnet.ahrq.gov/node/60548/psn-pdf
May 28, 2020 - ’ve expanded the scope of what we view as “critical” for assuring the safety of products, and that
includes … This includes our Breakthrough Devices Program, which covers
devices intended to treat or diagnose life … This includes our work establishing
medical device registries, our increasing work with industry, and
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psnet.ahrq.gov/node/47328/psn-pdf
January 01, 2020 - The program measures HAC rates by a composite Patient Safety
Indicator (PSI90), which includes 10 specific
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psnet.ahrq.gov/node/60174/psn-pdf
March 30, 2020 - Most notably, this third edition includes
a chapter on cross-cutting topics that are not related to … , diagnostic errors, delirium, adverse drug events, and others.[5] This edition of the report
also includes
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psnet.ahrq.gov/node/848107/psn-pdf
April 26, 2023 - This perspective includes the contribution of Dr. … Graber’s pioneering work on diagnostic error in 2005, which includes an identification of
systemic problems … Clinical decision making is a complex process that includes a variety of factors. … Clinician-centered misdiagnosis is only a part of overall diagnostic safety; the NASEM definition also
includes … guidance that scales to particular needs at the
level of individual practitioner whose scope of work includes
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psnet.ahrq.gov/node/863641/psn-pdf
February 28, 2024 - It includes a welcome
guide specific to the patients and family caregiver audience. … The website also includes new simulation-based training modules, which
can be used as tools to help … The core TeamSTEPPS materials on the website begin with an
Introduction, which includes an overview
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psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - Relevant documentation includes the case history, physical examination, signed consent form, and pre-anesthesia … unlike verification for medication or imaging orders, the standard protocol for verifying procedures includes … established in the 1980s, IR has been transitioning to a more clinically focused care delivery model that includes … Global Consensus Statement Defining Interventional Radiology, the clinical scope and practice of IR includes
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psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
September 01, 2017 - adequate data for further improvement—for instance, a daily monitoring report to the charge nurse that includes … Joint Commission recommends that each organization's: "process for effective hand off communication includes … Clinical content Includes everything on the data-information-knowledge continuum stored in the … Human–computer interface Enables unrelated entities to interact with the system and includes aspects
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psnet.ahrq.gov/node/33707/psn-pdf
February 01, 2011 - Research and QI projects
Course content includes
(but not limited to): systems
failure and medical … interventions in CQI
framework and designing
additional or new
interventions
Duration: 6 days
Course includes … Duration: 20 days
Course includes lectures
from national experts and
completion and reporting of … science, support
to attend meetings, and
bonuses for good
performance
Duration: 8 hours
Program includes
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psnet.ahrq.gov/node/49732/psn-pdf
May 01, 2015 - , sepsis always involves activation of the host inflammatory response and, in more serious
states, includes … updated in 2013 by the Surviving Sepsis Campaign (SSC) and endorsed by multiple
medical societies, includes … timely manner.(4) Based on an
initial protocol performed by Rivers and colleagues (5), the bundle includes … UCSF Bundle Compliance and Mortality (Includes All Adult Inpatients and the Emergency
Department).
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
May 01, 2015 - initiated by an infection
Sepsis always involves activation of the host inflammatory response and often includes … treatment with the "resuscitation bundle"
The bundle, updated in the Surviving Sepsis Campaign in 2013, includes … www.ncbi.nlm.nih.gov/pubmed/23353941
12
Resuscitation Bundle
Based on a NEJM study published in 2001, the bundle includes