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Showing results for "institutional".

2081. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36860/psn-pdf
      January 20, 2016 - IHI Global Trigger Tool for Measuring Adverse Events. 2nd Edition. January 20, 2016 Griffin FA, Resar RK. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009. https://psnet.ahrq.gov/issue/ihi-global-trigger-tool-measuring-adverse-events-2nd-edition This white paper describ…

2082. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865570/psn-pdf
      April 10, 2024 - Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner April 10, 2024 https://psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive- approach-data Summary North American Partners…

2083. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49853/psn-pdf
      February 01, 2019 - Adverse Event During Intrahospital Transport February 1, 2019 Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport The Case A 4-year-old boy underwent surgery under general anesthesia for correction o…

2084. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49465/psn-pdf
      December 22, 2021 - Electronic Err October 1, 2004 Tang PC. Electronic Err. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/electronic-err The Case A 75-year-old woman with coronary artery disease presented to the emergency department (ED) with chest pain that that had not responded to three sublingual nitroglycerin tablets at…

2085. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49616/psn-pdf
      December 01, 2010 - Milliliters vs. Milligrams December 1, 2010 Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams The Case   A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His evaluation showed acu…

2086. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45624/psn-pdf
      November 02, 2016 - Addressing the Opioid Crisis in the United States. November 2, 2016 Martin L, Laderman M, Hyatt J, Krueger J. Cambridge, MA: Institute for Healthcare Improvement; April 2016. https://psnet.ahrq.gov/issue/addressing-opioid-crisis-united-states Misuse of opioid medications is currently a serious patient safety conce…

2087. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43328/psn-pdf
      August 20, 2018 - Safety Quality and Informatics Leadership Program. August 20, 2018 Harvard Medical School, Boston, MA https://psnet.ahrq.gov/issue/safety-quality-and-informatics-leadership-program The Institute of Medicine's learning health system concept serves as the foundation for this year-long curriculum covering how to appl…

2088. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47966/psn-pdf
      May 29, 2019 - Patient Safety Essentials Toolkit. May 29, 2019 Boston, MA: Institute for Healthcare Improvement; 2019. https://psnet.ahrq.gov/issue/patient-safety-essentials-toolkit This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis, and communication as well as templates to …

2089. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44917/psn-pdf
      November 30, 2016 - Canadian Incident Analysis Framework. November 30, 2016 Incident Analysis Collaborating Parties. Edmonton, AB: Canadian Patient Safety Institute; 2012. ISBN: 9781926541440. https://psnet.ahrq.gov/issue/canadian-incident-analysis-framework Performing incident analysis can help organizations understand why adverse e…

2090. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35283/psn-pdf
      July 14, 2010 - Hospitalists as emerging leaders in patient safety: targeting a few to affect many. July 14, 2010 Flanders SA, Kaufman SR, Saint S, et al. Hospitalists as emerging leaders in patient safety: targeting a few to affect many. J Patient Saf. 2005;1(2):78-82. doi:10.1097/pts.0b013e31819751f2. https://psnet.ahrq.gov/iss…

2091. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60189/psn-pdf
      April 01, 2020 - Eliminating Medication Overload: A National Action Plan. April 1, 2020 Working Group on Medication Overload. Brookline, MA: Lown Institute; 2020. https://psnet.ahrq.gov/issue/eliminating-medication-overload-national-action-plan Polypharmacy and medication overuse are known contributors to patient harm. This report …

2092. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42812/psn-pdf
      August 02, 2016 - Healthcare Practitioner’s Vaccine Error Reporting Form. August 2, 2016 Institute for Safe Medication Practices. https://psnet.ahrq.gov/issue/healthcare-practitioners-vaccine-error-reporting-form This form collects data on errors and concerns associated with vaccines as part of a national reporting program tracking…

2093. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34733/psn-pdf
      November 19, 2015 - Out of the Crisis. November 19, 2015 Deming WE. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering Study, 1986. ISBN: 9780911379013. https://psnet.ahrq.gov/issue/out-crisis Deming believes that American companies need to transform their method of management to engage and compete…

2094. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863762/psn-pdf
      March 14, 2024 - Diagnostic Excellence: a Patient Safety Awareness Week Webinar. March 6, 2024 Institute for Healthcare Improvement. March 14, 2024. https://psnet.ahrq.gov/issue/diagnostic-excellence-patient-safety-awareness-week-webinar Diagnostic safety is core to care without harm. This webinar aligned with the 2024 Patient Saf…

2095. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44007/psn-pdf
      April 01, 2015 - Time to tackle diagnostic errors. Physicians blame patient 'treadmill' for missed calls. April 1, 2015 Rice S. Time to tackle diagnostic errors. Physicians blame patient 'treadmill' for missed calls. Modern healthcare. 2015;45(3):18-20. https://psnet.ahrq.gov/issue/time-tackle-diagnostic-errors-physicians-blame-pa…

2096. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44115/psn-pdf
      June 03, 2015 - An approach to assessing patient safety in hospitals in low-income countries. June 3, 2015 Lindfield R, Knight A, Bwonya D. An approach to assessing patient safety in hospitals in low-income countries. PLoS One. 2015;10(3):e0121628. doi:10.1371/journal.pone.0121628. https://psnet.ahrq.gov/issue/approach-assessing-…

2097. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40646/psn-pdf
      July 27, 2011 - Engineering a Learning Healthcare System: A Look at the Future: Workshop Summary. July 27, 2011 Grossmann C, Goolsby WA, Olsen L, McGinnis JM; Institute of Medicine and National Academy of Engineering. Washington, DC: The National Academies Press; 2011. ISBN: 9780309120647. https://psnet.ahrq.gov/issue/engineering…

2098. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33703/psn-pdf
      November 01, 2010 - Are We Getting Better at Measuring Patient Safety? November 1, 2010 Rosen AK. Are We Getting Better at Measuring Patient Safety? PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety Perspective The past decade has witnessed unprecedented interest in patient safe…

2099. Double Trouble | PSNet
      psnet.ahrq.gov/web-mm/double-trouble
      August 01, 2012 - SPOTLIGHT CASE Double Trouble Citation Text: Gurwitz JH. Double Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

2100. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49531/psn-pdf
      March 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses…