-
psnet.ahrq.gov/node/42302/psn-pdf
May 29, 2013 - air transport is generally safe, this analysis of quality assurance reports found that
most errors involved
-
psnet.ahrq.gov/node/39096/psn-pdf
February 08, 2010 - A few well-publicized cases of medical errors have led the hospitals
involved to transform how they
-
psnet.ahrq.gov/node/43800/psn-pdf
August 02, 2016 - publication covers patient safety culture including its background in high-risk industries, key concepts
involved
-
psnet.ahrq.gov/node/36193/psn-pdf
September 30, 2010 - ethics-using-qi-methods-improve-health-care-quality-and-safety
The participants in this AHRQ–funded project explored the ethical issues involved
-
psnet.ahrq.gov/node/35020/psn-pdf
June 22, 2009 - surgical-skill-predicted-ability-detect-errors
The investigators observed surgeons participating in three skills tests, one of which involved
-
psnet.ahrq.gov/node/44632/psn-pdf
March 24, 2016 - hospital, potential risks associated with
double-booked cases, lack of transparency with patients involved
-
psnet.ahrq.gov/node/40863/psn-pdf
October 19, 2011 - family-woman-who-died-after-medical-error-joins-hospitals-safety-panel
Reporting on a fatal medical error, this article describes how the family became involved
-
psnet.ahrq.gov/node/39326/psn-pdf
July 31, 2012 - This Web site provides information on an initiative to reduce radiation exposure and mitigate risks involved
-
psnet.ahrq.gov/node/37237/psn-pdf
December 15, 2011 - analyzes one Swedish medication error incident that resulted in criminal charges against the
nurse involved
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.158_slideshow.ppt
September 01, 2007 - specialists, outpatient medical records, hospital discharge summaries, community pharmacies
Many disciplines involved … Best Practices in Medication Reconciliation
Given the number of disciplines involved in the medication-use … multi-disciplinary team and responsibilities for each component of the process assigned to the parties involved … preventable adverse events
To design a robust medication reconciliation process, first define steps involved
-
psnet.ahrq.gov/node/49664/psn-pdf
January 01, 2013 - In a study of 60 surgical malpractice claims associated with poor
communication, 43% involved poor handoffs … checklist and standardized
communication, and a joint plan developed by the multiprofessional teams involved … situational picture and
goals
Briefings
A specific phase for
information transfer
All team members
involved … about having the
best people but having
people who work
together")
Involvement
All team members
involved … Consultants maintain overall
picture and awareness by
standing back and monitoring
rather than being involved
-
psnet.ahrq.gov/node/40346/psn-pdf
November 26, 2014 - psnet.ahrq.gov/issue/inability-providers-predict-unplanned-readmissions
None of the providers directly involved
-
psnet.ahrq.gov/node/46617/psn-pdf
February 21, 2018 - emotional-impact-medical-errors-practicing-physicians-united-states-and-canada
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
-
psnet.ahrq.gov/node/43396/psn-pdf
July 30, 2014 - psnet.ahrq.gov/issue/patient-safety-and-quality-care
This commentary reveals insights from a physician who was involved
-
psnet.ahrq.gov/node/37774/psn-pdf
June 11, 2008 - discovered that 33% of patients being treated with acetylcysteine for an acetaminophen
overdose were involved
-
psnet.ahrq.gov/node/41576/psn-pdf
October 11, 2012 - role-talking-and-keeping-silent-physician-coping-medical-error-qualitative-study
This qualitative study examines the coping strategies that physicians used after being involved
-
psnet.ahrq.gov/node/41038/psn-pdf
February 10, 2012 - describes an initiative to ensure that relevant patient safety information is accessible for
organizations involved
-
psnet.ahrq.gov/node/39304/psn-pdf
February 17, 2010 - involving antidepressants most commonly
occurred at the medication administration stage and frequently involved
-
psnet.ahrq.gov/node/47678/psn-pdf
December 19, 2018 - patient safety and covers topics
such as the epidemiology of error, its impact on the individuals involved
-
psnet.ahrq.gov/node/41304/psn-pdf
June 01, 2012 - found that those lower on the authority gradient expressed more fear of being punished if they
were involved