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Total Results: 7,150 records

Showing results for "involved".

201. An Untimely End Despite End-of-Life Care Planning | PSNet
     psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
     February 01, 2012 - The ICU resident, who had been involved in the prior conversations, canceled the terminal extubation … Another nurse who had been involved in the previous conversations found the canceled orders after the … Additionally, the supervising physicians were not involved with or aware of the order writing and canceling … process and were only involved after the extubation was complete. … is a multidisciplinary, multiteam meeting called by the nurse in charge of the patient, and all the involved

202. How to develop a second victim support program: a toolkit for health care organizations. | PSNet
     psnet.ahrq.gov/issue/how-develop-second-victim-support-program-toolkit-health-care-organizations
     April 03, 2019 - April 10, 2019 Supporting involved health care professionals (second victims) following … September 19, 2016 Supporting involved health care professionals (second victims) following

203. Nurse Wellbeing and Patient Safety | PSNet
     psnet.ahrq.gov/curated-library/nurse-wellbeing-and-patient-safety
     August 30, 2023 - Healthcare workers who are involved in a patient safety incident may experience adverse psychological … Becoming a high reliability organization remains challenging due to the many contributing factors involved … Medical errors and adverse events can have a devastating psychological impact on the providers involved … Conducted in 2021, this study involved 867 hospital nurses in the United States. … Healthcare workers who are involved in a patient safety incident may experience adverse psychological

204. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49603/psn-pdf
     June 01, 2010 - Upon discovery of the error, the nurse involved was fired by the hospital and her license was revoked … or at-risk/reckless behavior is a very difficult judgment, and the outcome depends more on who is involved … Second, determine the (clinical) knowledge of the person involved: did he or she have sufficient training … What does the person involved believe should be done? … organization's risk, but it is probably seen as very unjust by all other major stakeholders: the nurse involved

205. Wisdom through adversity: learning and growing in the wake of an error. | PSNet
     psnet.ahrq.gov/issue/wisdom-through-adversity-learning-and-growing-wake-error
     October 08, 2016 - themselves as having increased compassion, humility, and tolerance for uncertainty as a result of being involved … This study illustrates the second victim phenomenon that affects many clinicians who are involved in

206. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/863649/psn-pdf
     February 28, 2024 - Stephen Hines: I have been involved with TeamSTEPPS since the early 2000s, including the initial TeamSTEPPS … I was also involved with leading the AHRQ-funded National Training program and leading national conferences … Sarah Mossburg: What organizations or stakeholders were involved in the revisions? … We also wanted to make sure that we had representatives who were extensively involved in virtual care … We’d like to thank all those involved for their dedicated and thoughtful contributions.

207. Controversy and quality improvement: lingering questions about ethics, oversight, and patient safety research. | PSNet
     psnet.ahrq.gov/issue/controversy-and-quality-improvement-lingering-questions-about-ethics-oversight-and-patient
     January 15, 2014 - anonymously filed complaint, acted due to concerns around the need for consent from patients and clinicians involved … This commentary summarizes the project in question, discusses several ethical and regulatory issues involved

208. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45222/psn-pdf
     June 08, 2016 - The effort involved socioadaptive interventions (various approaches shown to improve safety culture) … An earlier article described the implementation of the program, which involved collaboration between

209. Responding to Patient Safety Events | PSNet
     psnet.ahrq.gov/primer/responding-patient-safety-events
     October 18, 2023 - Communication and Remediation Ongoing and timely communication with healthcare staff, patients, and families involved … In the aftermath of a patient safety event, healthcare staff involved could face feelings of guilt, inadequacy … Staff involved may feel personally responsible for the patient safety event and question their own knowledge … For more information, see related primer, Second Victims: Support for Clinicians Involved in Errors

210. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49681/psn-pdf
     April 01, 2013 - .(6) Making PN Use Safer In addition to standardization of the process and the expertise of those involved … Health care providers involved with PN should be knowledgeable and skilled in patient PN management … Caregivers involved with PN should work within an interdisciplinary setting that includes certified … When knowledgeable pharmacists are involved, pediatric PN prescribing errors are identified and resolved … It is the responsibility of the involved prescriber, pharmacist, nurse, and dietitian to recognize and

211. ISMP Education Solutions | PSNet
     psnet.ahrq.gov/training-catalog/ismp-education-solutions
     August 09, 2025 - As a global leader in medication safety education, ISMP provides innovative programs for all staff involved

212. Changing course. | PSNet
     psnet.ahrq.gov/issue/changing-course
     March 26, 2014 - A few well-publicized cases of medical errors have led the hospitals involved to transform how they approach … A few well-publicized cases of medical errors have led the hospitals involved to transform how they approach

213. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33571/psn-pdf
     March 15, 2025 - used as a general term for all voluntary patient safety event reporting systems, which rely on those involved … Initial reports often come from the frontline personnel directly involved in an event or the actions … Because event reports usually are submitted by personnel involved in the events themselves, these caregivers

214. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49866/psn-pdf
     June 01, 2019 - as well as chart review to identify medication errors, investigators determined that 44% of cases involved … The medications most frequently involved included propofol, phenylephrine, and fentanyl, and errors … described a tendency toward self-doubt in novel or ambiguous situations.(5-8) In this case, the resident involved … rooms alone, that the attending is physically accessible for consultation at all times, and that the involved

215. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/860015/psn-pdf
     September 01, 2024 - that received administrative penalties from 2007-2011 were distributed as follows: 46 cases (58%) involved … sponges, and 4 towels 16/46 (35%) of these cases came from obstetric or gynecology areas. 0 cases involved … reported, because they were not retrieved and were not considered to cause harm). 24 cases (30%) involved … SMI and device fragments. 9 cases (11%) involved instruments. 7/9 cases involved one type of instrument

216. The Different Count Contributions to Retention (pdf file)
     psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
     January 01, 2024 - important to identify the work performance errors and failed communication strategies of the stakeholders involved … Of the 46 cases, 39 (85%) involved sponge retention in the abdomen or pelvis. … is included with the correct count cases because the case was documented as having a correct count, involved … The ICRC also illustrates the multi- stakeholder errors which are involved and ways that hospitals have … The NCRC that involved the retained raytex in the spine was the result of a specific policy for spine

217. A program to prevent catheter-associated urinary tract infection in acute care. | PSNet
     psnet.ahrq.gov/issue/program-prevent-catheter-associated-urinary-tract-infection-acute-care
     December 21, 2017 - The effort involved socioadaptive interventions (various approaches shown to improve safety culture) … An earlier article described the implementation of the program, which involved collaboration between

218. In Conversation With… Sidney Dekker, MA, MSc, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
     February 26, 2025 - This is what they should do: Sit back and think very, very carefully about who is going to be involved … Having that perspective involved, that viewpoint for whom the world looks quite differently inside of … The resilience of individuals involved, at least the ones that I have been involved with, seems to be … So I think that the harsh responses to individuals involved in adverse events are unfruitful and unfair … Whereas, if we have more restorative justice, take the person who was involved in this and have them

219. Total Parenteral Nutrition, Multifarious Errors | PSNet
     psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
     January 23, 2017 - Health care providers involved with PN should be knowledgeable and skilled in patient PN management and … Caregivers involved with PN should work within an interdisciplinary setting that includes certified nutrition … The error in this case involved a breakdown in oversight and system checks; breakdowns leading to medication … When knowledgeable pharmacists are involved, pediatric PN prescribing errors are identified and resolved … It is the responsibility of the involved prescriber, pharmacist, nurse, and dietitian to recognize and

220. Implementing and evaluating patient-focused safety technology on adult acute mental health wards. | PSNet
     psnet.ahrq.gov/issue/implementing-and-evaluating-patient-focused-safety-technology-adult-acute-mental-health-wards
     April 06, 2022 - Citation Related Resources From the Same Author(s) To what extent are patients involved … October 5, 2022 To what extent are patients involved in researching safety in acute mental