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Showing results for "institutional".

2281. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72762/psn-pdf
      February 17, 2021 - Optimizing Health IT for Safe Integration of Behavioral Health and Primary Care. February 17, 2021 Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021. https://psnet.ahrq.gov/issue/optimizing-health-it-safe-integration-behavioral-health-and-primary-care Effective integration of hea…

2282. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47855/psn-pdf
      June 19, 2019 - Medication Overload: America's Other Drug Problem. June 19, 2019 Brownlee S; Garber J. Brookline, MA: Lown Institute; 2019. https://psnet.ahrq.gov/issue/medication-overload-americas-other-drug-problem Overprescribing is a common problem that contributes to patient harm. This report examines financial, clinical, an…

2283. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45565/psn-pdf
      May 24, 2017 - Leading a Culture of Safety: a Blueprint for Success. May 24, 2017 Chicago, IL: American College of Healthcare Executives, National Patient Safety Foundation's Lucian Leape Institute; 2017. https://psnet.ahrq.gov/issue/leading-culture-safety-blueprint-success Health care leadership plays an undeniable role in sust…

2284. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46286/psn-pdf
      September 13, 2017 - Preventing blood transfusion failures: FMEA, an effective assessment method. September 13, 2017 Najafpour Z, Hasoumi M, Behzadi F, et al. Preventing blood transfusion failures: FMEA, an effective assessment method. BMC Health Serv Res. 2017;17(1):453. doi:10.1186/s12913-017-2380-3. https://psnet.ahrq.gov/issue/pre…

2285. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38938/psn-pdf
      July 26, 2023 - ISMP's List of Confused Drug Names. July 26, 2023 Horsham, PA; Institute for Safe Medication Practices: July 2023. https://psnet.ahrq.gov/issue/ismps-list-confused-drug-names Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet provides a comprehensive list of commonly…

2286. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37809/psn-pdf
      November 21, 2016 - Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: Recommendations and Promising Practices. November 21, 2016 Johnson B, Abraham M, Conway J, et al. Bethesda, MD: Institute for Family-Centered Care; April 2008. https://psnet.ahrq.gov/issue/partnering-patients-and-fam…

2287. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837042/psn-pdf
      April 04, 2022 - Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management. April 4, 2022 Institute for Healthcare Improvement. https://psnet.ahrq.gov/issue/leadership-response-sentinel-event-respectful-effective-crisis-management Crisis management skills are valuable at both the organizational and clinical …

2288. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43677/psn-pdf
      November 19, 2014 - Reporting and Learning Systems for Medication Errors: The Role of Pharmacovigilance Centres. November 19, 2014 Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October 2014. ISBN: 9789241507943. https://psnet.ahrq.gov/issue/reporting-and-learning-systems-medication-err…

2289. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47627/psn-pdf
      January 16, 2019 - Safety of overlapping inpatient orthopaedic surgery: a multicenter study. January 16, 2019 Dy CJ, Osei DA, Maak TG, et al. Safety of Overlapping Inpatient Orthopaedic Surgery: A Multicenter Study. J Bone Joint Surg Am. 2018;100(22):1902-1911. doi:10.2106/JBJS.17.01625. https://psnet.ahrq.gov/issue/safety-overlappi…

2290. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44041/psn-pdf
      April 01, 2015 - Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection. April 1, 2015 National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. March 23, 2015 https://psnet.ahrq.gov/issue/pot…

2291. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74762/psn-pdf
      February 09, 2022 - Start the year off right by addressing these top 10 medication safety concerns from 2021. February 9, 2022 ISMP Medication Safety Alert! Acute care edition. January 27, 2022;27(2):1-6. https://psnet.ahrq.gov/issue/start-year-right-addressing-these-top-10-medication-safety-concerns-2021 Medication errors are a cons…

2292. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50867/psn-pdf
      February 05, 2020 - Cognitive testing of older clinicians prior to recredentialing. February 5, 2020 Cooney L, Balcezak T. Cognitive Testing of Older Clinicians Prior to Recredentialing. JAMA. 2020;323(2):179-180. doi:10.1001/jama.2019.18665. https://psnet.ahrq.gov/issue/cognitive-testing-older-clinicians-prior-recredentialing In an…

2293. Latent Error (or Latent Condition) | PSNet
      psnet.ahrq.gov/glossary/latent-error-or-latent-condition
      September 13, 2021 - Latent Error (or Latent Condition) September 13, 2021 Anonymous (not verified) The terms active and latent as applied to errors were coined by Reason . Latent errors (or latent conditions) refer to less apparent failures of organization or design that contributed to the occurrence of errors or allowed them…

2294. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867849/psn-pdf
      February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety In To Err I…

2295. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841567/psn-pdf
      December 14, 2022 - Measuring Patient Safety December 14, 2022 Schreiber M, Van C, Mossburg SE. Measuring Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/measuring-patient-safety Following the landmark report To Err is Human: Building a Safer Health System, developed by the Institute of Medicine in 1999, pa…

2296. Walking Patient, Missing Drain | PSNet
      psnet.ahrq.gov/web-mm/walking-patient-missing-drain
      April 01, 2006 - Walking Patient, Missing Drain Citation Text: Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote …

2297. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49769/psn-pdf
      September 01, 2016 - Complaints as Safety Surveillance September 1, 2016 Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance The Case A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain came on sudden…

2298. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49592/psn-pdf
      October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…

2299. Rethinking Root Cause Analysis | PSNet
      psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
      August 21, 2016 - Annual Perspective Rethinking Root Cause Analysis Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD | January 1, 2016  View more articles from the same authors. Citation Text: Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. Rockville (MD): Age…

2300. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.335_slideshow.ppt
      December 01, 2014 - PowerPoint Presentation Spotlight A Stroke of Error This presentation is based on the December 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Kevin M. Barrett, MD, MSc, Consultant, Associate Professor of Neurology, Director, Neurohospitalist F…