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psnet.ahrq.gov/issue/fda-public-health-notification-unretrieved-device-fragments
June 02, 2021 - Safety considerations to mitigate the risks of misconnections with small-bore connectors intended
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psnet.ahrq.gov/node/44180/psn-pdf
June 21, 2015 - Ken Kizer, former CEO of the National Quality Forum (NQF), the term was
originally intended to refer
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psnet.ahrq.gov/issue/implementation-custom-alert-prevent-medication-timing-errors-associated-computerized
April 25, 2016 - This study examined the effect of a custom alert intended to reduce medication-timing errors associated
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psnet.ahrq.gov/issue/implementation-josie-king-care-journal-pediatric-intensive-care-unit-quality-improvement
November 21, 2016 - The Josie King Care Journal is a tool intended to improve communication between the health care team
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psnet.ahrq.gov/issue/adoption-electronic-health-records-grows-rapidly-fewer-half-us-hospitals-had-least-basic
August 07, 2013 - Despite considerable federal financial incentives intended to promote electronic health record (EHR)
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psnet.ahrq.gov/issue/considerations-design-safe-and-effective-consumer-health-it-applications-home
September 24, 2016 - evaluates the role of human factors and ergonomics in the design and implementation of five IT applications intended
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psnet.ahrq.gov/issue/errors-nurse-led-triage-observational-study
August 20, 2018 - Emergency department triage systems are intended to prioritize patients based on illness severity,
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psnet.ahrq.gov/issue/programmable-infusion-pumps-icus-analysis-corresponding-adverse-drug-events
January 16, 2008 - Adoption of smart infusion pump technology was intended to improve medication safety, but past reports
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psnet.ahrq.gov/issue/overrides-medication-related-clinical-decision-support-alerts-outpatients
September 01, 2016 - Although computerized provider order entry in the outpatient setting was intended to prevent medication
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psnet.ahrq.gov/issue/impact-nurse-led-rapid-response-system-adverse-major-adverse-events-and-activation-medical
December 17, 2010 - This study of an after-hours rapid response team found that the team was not always activated as intended
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psnet.ahrq.gov/issue/digital-health-intervention-patient-safety-children-and-parents-scoping-review
January 23, 2017 - This scoping review characterized 13 articles exploring the use of digital interventions intended to
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psnet.ahrq.gov/issue/multicompartment-compliance-aids-community-prevalence-potentially-inappropriate-medications
January 30, 2013 - The aids are intended to improve medication safety and adherence for patients taking multiple medications
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psnet.ahrq.gov/issue/identifying-and-characterizing-preventable-adverse-drug-events-prioritizing-pharmacist
July 15, 2010 - This study reports the results of a literature review and expert panel process intended to assess the
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psnet.ahrq.gov/issue/use-patient-digital-facial-images-confirm-patient-identity-childrens-hospitals-anesthesia
May 06, 2009 - The Universal Protocol was intended to prevent wrong site, wrong procedure and wrong person surgery
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psnet.ahrq.gov/issue/how-effective-teamwork-really-relationship-between-teamwork-and-performance-healthcare-teams
February 14, 2017 - outcomes, such as postoperative infection rates, and process measures, such as adherence to checklists intended
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psnet.ahrq.gov/issue/joint-commissions-ongoing-professional-practice-evaluation-process-costly-ineffective-and
July 01, 2017 - Accreditation by organizations such as The Joint Commission (TJC) is intended to improve quality of
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psnet.ahrq.gov/issue/bone-break-hot-debrief-tool-reduce-second-victim-syndrome-nurses
August 02, 2015 - The tool, BONE Break (Buoy/Break, Open-Up, Needs, Exit/Evaluate), is intended to be used as soon as possible
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psnet.ahrq.gov/issue/establishing-multi-institutional-quality-and-patient-safety-consortium-collaboration-across
June 24, 2009 - Quality improvement and patient safety (QIPS) programs are intended to increase patient safety competency
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psnet.ahrq.gov/issue/omissions-care-nursing-homes-uniform-definition-research-and-quality-improvement
August 01, 2012 - concepts included in (and excluded from) the proposed definition, provides examples of omissions of care, intended
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psnet.ahrq.gov/issue/how-valid-icd-9-cm-based-ahrq-patient-safety-indicator-postoperative-venous-thromboembolism
April 03, 2017 - The AHRQ Patient Safety Indicators (PSIs) are intended for use in screening medical records to identify