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Showing results for "institution".

1701. Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center. | PSNet
      psnet.ahrq.gov/issue/one-pen-one-patient-achievable-hospital-quality-improvement-project-reduce-risks-inadvertent
      April 10, 2024 - Study Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center. Citation Text: Ho S, Stamm R, Hibbs M, et al. Is One-Pen, One-Patient Achievable in the Hospital? A Quality Impr…

1702. Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations. | PSNet
      psnet.ahrq.gov/issue/mind-gap-between-recommendation-and-implementation-principles-and-lessons-aftermath-incident
      March 11, 2020 - Study Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations. Citation Text: Wrigstad J, Bergström J, Gusta…

1703. Multidisciplinary approaches to reducing error and risk in a patient care setting. | PSNet
      psnet.ahrq.gov/issue/multidisciplinary-approaches-reducing-error-and-risk-patient-care-setting
      January 05, 2017 - Study Classic Multidisciplinary approaches to reducing error and risk in a patient care setting. Citation Text: Connor M, Ponte PR, Conway JB. Multidisciplinary approaches to reducing error and risk in a patient care setting. Crit Care Nurs Clin North Am. 2002…

1704. Ethical considerations in the development of the Flexibility in Duty Hour Requirements for Surgical Trainees trial. | PSNet
      psnet.ahrq.gov/issue/ethical-considerations-development-flexibility-duty-hour-requirements-surgical-trainees-trial
      June 21, 2017 - Commentary Ethical considerations in the development of the Flexibility in Duty Hour Requirements for Surgical Trainees trial. Citation Text: Minami CA, Odell DD, Bilimoria KY. Ethical Considerations in the Development of the Flexibility in Duty Hour Requirements for Surgical Trainees Tr…

1705. Creating a safer health care system: finding the constraint. | PSNet
      psnet.ahrq.gov/issue/creating-safer-health-care-system-finding-constraint
      February 24, 2011 - Commentary Creating a safer health care system: finding the constraint. Citation Text: Pauker SG, Zane EM, Salem D. Creating a safer health care system: finding the constraint. JAMA. 2005;294(22):2906-8. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML En…

1706. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38367/psn-pdf
      May 24, 2015 - Pathways for Patient Safety. May 24, 2015 Chicago, IL: Health Research and Educational Trust, Institute for Safe Medication Practices, Medical Group Management Association; 2009. https://psnet.ahrq.gov/issue/pathways-patient-safety This trio of modules provides ambulatory medical practices with tools to develop te…

1707. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35155/psn-pdf
      April 03, 2008 - Safer Healthcare Now! April 3, 2008 Canadian Patient Safety Institute. https://psnet.ahrq.gov/issue/safer-healthcare-now Originally launched in 2005, this campaign seeks to implement evidence-based strategies to improve patient safety in Canadian hospitals. In April 2008, the initiative added four new intervention…

1708. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38035/psn-pdf
      September 03, 2008 - Incentives for patient safety: holding healthcare executives accountable. September 3, 2008 ECRI Institute. Risk Management Reporter. August 2008;27:1-10. https://psnet.ahrq.gov/issue/incentives-patient-safety-holding-healthcare-executives-accountable This commentary discusses health care executive responsibility …

1709. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867655/psn-pdf
      February 26, 2025 - Learning Health Systems for Patient Safety February 26, 2025 Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety Despite an observable decrease in adverse events in health care over time, rat…

1710. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
      May 01, 2012 - Spotlight Case July 2008 Spotlight Case The Perils of Cross Coverage * * Source and Credits This presentation is based on the May 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …

1711. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.359_slideshow.ppt
      October 01, 2015 - PowerPoint Presentation Spotlight The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy 1 This presentation is based on the October 2015 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/ CME credit is available Commentary by: Jacob Reider,…

1712. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60653/psn-pdf
      April 25, 2020 - Health Care Delivery and Pharmacists During the COVID- 19 Pandemic June 29, 2020 Dopp AL, Fitall E, Hall KK, et al. Health Care Delivery and Pharmacists During the COVID-19 Pandemic. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic Medication…

1713. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49827/psn-pdf
      April 01, 2018 - Walking Patient, Missing Drain April 1, 2018 Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/walking-patient-missing-drain The Case A 43-year-old woman with a history of metastatic breast cancer was admitted to the hospital for an elective …

1714. Hemolysis Holdup | PSNet
      psnet.ahrq.gov/web-mm/hemolysis-holdup
      July 03, 2016 - Hemolysis Holdup Citation Text: Lehman CM. Hemolysis Holdup. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

1715. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38560/psn-pdf
      July 05, 2013 - Safe Surgery Saves Lives. July 5, 2013 Canadian Patient Safety Institute; CPSI. https://psnet.ahrq.gov/issue/safe-surgery-saves-lives This site supports the effort to adopt the World Alliance for Patient Safety surgical checklist program in Canada. https://psnet.ahrq.gov/issue/safe-surgery-saves-lives https://psn…

1716. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35589/psn-pdf
      June 17, 2010 - Health for life. Keys to safer hospitals. June 17, 2010 Berwick DM. Health for life. 6 keys to safer hospitals. Newsweek. 2005;146(24):76-8. https://psnet.ahrq.gov/issue/health-life-keys-safer-hospitals Institute for Healthcare Improvement President Don Berwick summarizes the six improvement measures of the 100K L…

1717. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38342/psn-pdf
      September 08, 2022 - Consumermedsafety.org September 8, 2022 Institute for Safe Medication Practices; 5200 Butler Pike, Plymouth Meeting, PA 19462. https://psnet.ahrq.gov/issue/consumermedsafetyorg This redesigned Web site provides information about drug safety alerts and allows consumers to help report and prevent medication errors. …

1718. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37085/psn-pdf
      July 15, 2013 - Critical Care Safety: Essentials for ICU Patient Care and Technology. July 15, 2013 Plymouth Meeting PA: ECRI Institute; 2007. ISBN 9780977914258. https://psnet.ahrq.gov/issue/critical-care-safety-essentials-icu-patient-care-and-technology This guide provides comprehensive tools for assessment, training, and imple…

1719. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36465/psn-pdf
      September 27, 2010 - An interview with Donald Berwick. September 27, 2010 Berwick DM. An interview with Donald Berwick. Interview by Paul M Schyve. Jt Comm J Qual Patient Saf. 2006;32(12):661-666. https://psnet.ahrq.gov/issue/interview-donald-berwick Dr. Berwick, president of the Institute for Healthcare Improvement, discusses his lif…

1720. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38687/psn-pdf
      June 03, 2009 - Disclosing errors that affect multiple patients. June 3, 2009 Chafe R, Levinson W, Sullivan T. Disclosing errors that affect multiple patients. CMAJ. 2009;180(11):1125- 7. doi:10.1503/cmaj.081016. https://psnet.ahrq.gov/issue/disclosing-errors-affect-multiple-patients This commentary describes strategies for discl…