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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33674/psn-pdf
    February 01, 2009 - In Conversation with…Robert M. Wachter, MD October 1, 2008 In Conversation with…Robert M. Wachter, MD. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md Editor's note: At the University of California, San Francisco, Robert M. Wachter, MD, is Professor and Chief of the…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49712/psn-pdf
    June 01, 2014 - May I Have Another?—Medication Error June 1, 2014 Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error The Case A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a pharmacology-tra…
  3. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.281_slideshow.ppt
    October 01, 2012 - Spotlight Case July 2008 Spotlight Case CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure * * Source and Credits This presentation is based on the October 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Catherine L…
  4. 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
  5. Psn-Pdf (pdf file)

    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
  6. psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
    December 23, 2020 - A Postpartum Woman with an Erroneous SARS-CoV-2 Test Citation Text: Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Forma…
  7. psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
    November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety Ronen Rozenblum, MD, MPH, and David Bates, MD, MS | November 1, 2017  Also Read a Conversation View more articles from the same authors. Citation Text: Rozenblum R, Bates DW. The Role…
  8. psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
    September 01, 2005 - Playing Well with Others: "Translocational Research" in Patient Safety Robert M. Wachter, MD | September 1, 2005  Also Read a Conversation View more articles from the same authors. Citation Text: Wachter R. Playing Well with Others: "Translocational Research" in…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852807/psn-pdf
    August 30, 2023 - Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia August 30, 2023 Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-…
  10. psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
    January 29, 2021 - Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia Citation Text: Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
  11. psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
    June 01, 2005 - Interpreting the Patient Safety Literature Kaveh G. Shojania, MD | June 1, 2005  Also Read a Conversation View more articles from the same authors. Citation Text: Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. Rockville (MD): Agency f…
  12. Psn-Pdf (pdf file)

    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
  13. Psn-Pdf (pdf file)

    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
  14. Psn-Pdf (pdf file)

    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
  15. Psn-Pdf (pdf file)

    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
  16. 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
  17. 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
  18. Psn-Pdf (pdf file)

    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
  19. Psn-Pdf (pdf file)

    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).
  20. 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

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