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Showing results for "institution".

1981. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38361/psn-pdf
      January 31, 2011 - IOM: shorten residents' work shifts to reduce fatigue, improve patient safety. January 31, 2011 Kuehn BM. IOM: Shorten residents' work shifts to reduce fatigue, improve patient safety. JAMA. 2009;301(3):259-61. doi:10.1001/jama.2008.940. https://psnet.ahrq.gov/issue/iom-shorten-residents-work-shifts-reduce-fatigue…

1982. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60534/psn-pdf
      May 27, 2020 - Hospital workers complain of minimal disclosure after COVID exposures. May 27, 2020 Gold J, Hawryluk M. Kaiser Health News. May 13, 2020. https://psnet.ahrq.gov/issue/hospital-workers-complain-minimal-disclosure-after-covid-exposures A successful safety culture is consistently evident across all areas of a hospita…

1983. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37023/psn-pdf
      September 24, 2010 - Applying the Toyota Production System: using a patient safety alert system to reduce error. September 24, 2010 Furman C, Caplan RA. Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf. 2007;33(7):376-386. https://psnet.ahrq.gov/issue/applying-toyot…

1984. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38305/psn-pdf
      January 15, 2009 - High-alert medications in the pediatric intensive care unit. January 15, 2009 Franke HA, Woods D, Holl JL. High-alert medications in the pediatric intensive care unit. Pediatr Crit Care Med. 2009;10(1):85-90. doi:10.1097/PCC.0b013e3181936ff8. https://psnet.ahrq.gov/issue/high-alert-medications-pediatric-intensive-c…

1985. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44223/psn-pdf
      November 22, 2016 - Patient Safety and Incident Management Toolkit. November 22, 2016 Edmonton, AB: Canadian Patient Safety Institute. June 2015. https://psnet.ahrq.gov/issue/patient-safety-and-incident-management-toolkit Engaging patients and families in safety can uncover concerns and inform improvement efforts. This three- compone…

1986. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44502/psn-pdf
      May 07, 2018 - Draft Guidelines for the Safe Communication of Electronic Medication Information. May 7, 2018 Institute for Safe Medication Practices. Acute Care Edition. August 27, 2015;2;1-3,6. https://psnet.ahrq.gov/issue/draft-guidelines-safe-communication-electronic-medication-information How electronic medication-related in…

1987. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73327/psn-pdf
      January 25, 2022 - ISMP Medication Safety Self Assessment® for Perioperative Settings. January 25, 2022 Institute for Safe Medication Practices https://psnet.ahrq.gov/issue/ismp-medication-safety-self-assessmentr-perioperative-settings The perioperative setting is a high-risk area for medication errors, should they occur. This asses…

1988. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34636/psn-pdf
      June 14, 2011 - The wrong patient. June 14, 2011 Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136(11):826-833. https://psnet.ahrq.gov/issue/wrong-patient This case study describes the events of a patient who underwent an unintended invasive cardiac electrophysiology study. While reviewing the details of the case…

1989. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43409/psn-pdf
      February 25, 2015 - Evaluating iatrogenic prescribing: development of an oncology-focused trigger tool. February 25, 2015 Hébert G, Netzer F, Ferrua M, et al. Evaluating iatrogenic prescribing: development of an oncology-focused trigger tool. Eur J Cancer. 2015;51(3):427-35. doi:10.1016/j.ejca.2014.12.002. https://psnet.ahrq.gov/issu…

1990. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44159/psn-pdf
      July 08, 2016 - Vital Signs: Core Metrics for Health and Health Care Progress. July 8, 2016 Blumenthal D, Malphrus E, McGinnis JM, eds. Committee on Core Metrics for Better Health at Lower Cost, Institute of Medicine. Washington, DC: National Academies Press; 2015. ISBN: 9780309324939. https://psnet.ahrq.gov/issue/vital-signs-cor…

1991. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60805/psn-pdf
      August 12, 2020 - A blueprint for leadership during COVID-19. August 12, 2020 Rosa WE, Schlak AE, Rushton CH. A blueprint for leadership during COVID-19. Nurs Manage. 2020;51(8):28-34. doi:10.1097/01.numa.0000688940.29231.6f. https://psnet.ahrq.gov/issue/blueprint-leadership-during-covid-19 These authors discuss the effect of the C…

1992. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60889/psn-pdf
      January 01, 2021 - Expert consensus on currently accepted measures of harm. September 9, 2020 Logan MS, Myers LC, Salmasian H, et al. Expert consensus on currently accepted measures of harm. J Patient Saf. 2021;17(8):e1726-e1731. doi:10.1097/pts.0000000000000754. https://psnet.ahrq.gov/issue/expert-consensus-currently-accepted-measu…

1993. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45890/psn-pdf
      February 15, 2017 - A Framework for Safe, Reliable, and Effective Care. February 15, 2017 Frankel A, Haraden C, Federico F, Lenoci-Edwards J. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017. https://psnet.ahrq.gov/issue/framework-safe-reliable-and-effective-care A systems approach to safety ca…

1994. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842432/psn-pdf
      January 11, 2023 - Medication errors: the year in review: January through December 2021. January 11, 2023 Pharmacy Practice News Special Edition. December 13, 2022: 43-54. https://psnet.ahrq.gov/issue/medication-errors-year-review-january-through-december-2021 Medication errors continue to occur despite long-standing efforts to redu…

1995. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34994/psn-pdf
      September 29, 2017 - Advances in Patient Safety: From Research to Implementation. September 29, 2017 Henriksen K, Battles JB, Marks ES, et al, eds. Rockville, MD: Agency for Healthcare Research and Quality (US); 2005. https://psnet.ahrq.gov/issue/advances-patient-safety-research-implementation With 4 volumes and 140 articles (all of …

1996. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42907/psn-pdf
      August 02, 2015 - Innovation in safety, and safety in innovation. August 2, 2015 Eisenberg D, Wren SM. Innovation in safety, and safety in innovation. JAMA Surg. 2014;149(1):7-9. doi:10.1001/jamasurg.2013.5112. https://psnet.ahrq.gov/issue/innovation-safety-and-safety-innovation This commentary discusses systems-focused innovations…

1997. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842775/psn-pdf
      January 18, 2023 - Safer Together Survey: Advancing Patient and Workforce Safety January 18, 2023 Cambridge, MA: Institute for Healthcare Improvement: January 2023. https://psnet.ahrq.gov/issue/safer-together-survey-advancing-patient-and-workforce-safety The National Steering Committee for Patient Safety (NSC) was formed to engage w…

1998. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43335/psn-pdf
      July 09, 2014 - Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. July 9, 2014 Tjia I, Rampersad S, Varughese AM, et al. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Anesth Analg. 2014;119(1):122-136. doi:10.1213/ANE.0000000000000266. https://psnet.ahrq.gov/is…

1999. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837979/psn-pdf
      August 31, 2022 - Maternal Health Research Centers of Excellence (U54 Clinical Trial Optional). August 31, 2022 National Institutes of Health.  August 11, 2022. RFA-HD-23-035. https://psnet.ahrq.gov/issue/maternal-health-research-centers-excellence-u54-clinical-trial-optional Maternity care is increasingly being recognized as …

2000. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34737/psn-pdf
      November 19, 2015 - First, Do No Harm Part 1: A Case Study of Systems Failure. November 19, 2015 Chicago: Partnership for Patient Safety, Harvard Risk Management Foundation; 2000. https://psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure This video, produced by the Partnership for Patient Safety and the Harvard …