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Showing results for "institutional".

  1. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
    February 26, 2025 - In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025  Also Read the Essay View more articles from the same authors. Citation T…

  2. The Evolution of Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/evolution-root-cause-analysis
    February 26, 2025 - The Evolution of Root Cause Analysis Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025  Also Read the Conversation View more articles from the same authors. Citation Text: Behrhorst J, Gale B, Van CM. Th…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48078/psn-pdf
    August 14, 2019 - Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit. August 14, 2019 Cifra CL, Houston M, Otto A, et al. Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit. Jt Comm J Qual Patient Saf. 2019;45(8):543-551. doi:10.…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47174/psn-pdf
    June 13, 2018 - Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages. June 13, 2018 National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. May 24, 2018. https://psnet.ahrq.gov/issue/safe-han…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45695/psn-pdf
    December 14, 2016 - Significant reduction in preanalytical errors for nonphlebotomy blood draws after implementation of a novel integrated specimen collection module. December 14, 2016 Le RD, Melanson SEF, Petrides AK, et al. Significant Reduction in Preanalytical Errors for Nonphlebotomy Blood Draws After Implementation of a Novel I…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865338/psn-pdf
    March 27, 2024 - Analysis of intervention employability in pharmacy- related medication safety reports at a tertiary medical center. March 27, 2024 Crozier N, Robinson E, Murtagh NC, et al. Analysis of intervention employability in pharmacy-related medication safety reports at a tertiary medical center. Hosp Pharm. 2024;59(2):210-…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36186/psn-pdf
    September 30, 2010 - Findings of the first consensus conference on medical emergency teams. September 30, 2010 DeVita MA, Bellomo R, Hillman KM, et al. Findings of the First Consensus Conference on Medical Emergency Teams*. Crit Care Med. 2006;34(9). doi:10.1097/01.ccm.0000235743.38172.6e. https://psnet.ahrq.gov/issue/findings-first-c…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35617/psn-pdf
    January 01, 2016 - Reconciling medications at admission: safe practice recommendations and implementation strategies. June 13, 2011 Rogers G, Alper E, Brunelle D, et al. Reconciling Medications at Admission: Safe Practice Recommendations and Implementation Strategies. Jt Comm J Qual Patient Saf. 2016;32(1):37-50. doi:10.1016/s1553-7…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47223/psn-pdf
    August 14, 2018 - Six Building Blocks: A Team-Based Approach to Improving Opioid Management in Primary Care. August 14, 2018 MacColl Center for Health Care Innovation at the Kaiser Permanente of Washington Research Institute, University of Washington. https://psnet.ahrq.gov/issue/six-building-blocks-team-based-approach-improving-op…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43287/psn-pdf
    July 02, 2014 - 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. July 2, 2014 Wrigstad J, Bergström J, Gustafson P. Mind the gap between recom…

  11. Center for Consumer Health Care Information Patient Safety Center. | PSNet

    psnet.ahrq.gov/issue/center-consumer-health-care-information-patient-safety-center
    February 04, 2025 - Multi-use Website Center for Consumer Health Care Information Patient Safety Center. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL March 6, 2005 The Center's efforts for pati…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47379/psn-pdf
    November 14, 2018 - Analysis of medication therapy discontinuation orders in new electronic prescriptions and opportunities for implementing CancelRx. November 14, 2018 Yang Y, Ward-Charlerie S, Kashyap N, et al. Analysis of medication therapy discontinuation orders in new electronic prescriptions and opportunities for implementing C…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34678/psn-pdf
    February 09, 2011 - Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. February 9, 2011 Shojania KG, Burton EC, McDonald KM, et al. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA. 2003;289(21):2849-2856. https://psnet.ahrq.gov/issue/changes-rates-autopsy…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35309/psn-pdf
    January 02, 2017 - Advising patients about patient safety: current initiatives risk shifting responsibility. January 2, 2017 Entwistle V, Mello MM, Brennan TA. Advising Patients About Patient Safety: Current Initiatives Risk Shifting Responsibility. Jt Comm J Qual Patient Saf. 2005;31(9):483-494. doi:10.1016/s1553- 7250(05)31063-4. …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44322/psn-pdf
    June 21, 2016 - Emotional harm from disrespect: the neglected preventable harm. June 21, 2016 Sokol-Hessner L, Folcarelli P, Sands KEF. Emotional harm from disrespect: the neglected preventable harm. BMJ Qual Saf. 2015;24(9):550-3. doi:10.1136/bmjqs-2015-004034. https://psnet.ahrq.gov/issue/emotional-harm-disrespect-neglected-pre…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44773/psn-pdf
    January 13, 2016 - A tool for the concise analysis of patient safety incidents. January 13, 2016 Pham JC, Hoffman C, Popescu I, et al. A Tool for the Concise Analysis of Patient Safety Incidents. Jt Comm J Qual Patient Saf. 2016;42(1):26-33. https://psnet.ahrq.gov/issue/tool-concise-analysis-patient-safety-incidents Once identified,…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46546/psn-pdf
    January 10, 2018 - Using an online quiz-based reinforcement system to teach healthcare quality and patient safety and care transitions at the University of California. January 10, 2018 Shaikh U, Afsar-Manesh N, Amin AN, et al. Using an online quiz-based reinforcement system to teach healthcare quality and patient safety and care tra…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837599/psn-pdf
    June 29, 2022 - Differences in medication reconciliation interventions between six hospitals: a mixed method study. June 29, 2022 Stuijt CCM, van den Bemt BJF, Boerlage VE, et al. Differences in medication reconciliation interventions between six hospitals: a mixed method study. BMC Health Serv Res. 2022;22(1):722. doi:10.1186/s12…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72790/psn-pdf
    March 03, 2021 - Parent engagement in perinatal mortality reviews: an online survey of clinicians from six high-income countries. March 3, 2021 Boyle FM, Horey D, Siassakos D, et al. Parent engagement in perinatal mortality reviews: an online survey of clinicians from six high?income countries. BJOG. 2020;128(4):696-703. doi:10.11…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47284/psn-pdf
    December 05, 2018 - Preventable anesthesia-related adverse events at a large tertiary care center: a nine-year retrospective analysis. December 5, 2018 Curatolo CJ, McCormick PJ, Hyman JB, et al. Preventable Anesthesia-Related Adverse Events at a Large Tertiary Care Center: A Nine-Year Retrospective Analysis. Jt Comm J Qual Patient Sa…
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