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psnet.ahrq.gov/node/43596/psn-pdf
December 19, 2014 - role-anesthesiologist-perioperative-patient-safety
Although the anesthesiology field has long been involved
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psnet.ahrq.gov/node/46682/psn-pdf
January 24, 2018 - This
report describes the work and outcomes of a 3-year surgical safety program funded by AHRQ that involved
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psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - 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
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psnet.ahrq.gov/node/49543/psn-pdf
September 01, 2007 - In addition, each of the major disciplines
involved, including physicians, nurses, and pharmacists, … prevent mix-ups between "sound-alike" pharmaceuticals, hold significant promise, the multitude of errors
involved … learning collaboratives (14,15,17) and published literature (7,18,19):
Given the number of disciplines involved … multidisciplinary team, and
responsibilities for each component of the process must be assigned to the parties involved … To design a robust medication reconciliation process, first define steps involved and decide who
should
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psnet.ahrq.gov/node/44212/psn-pdf
September 19, 2016 - assessing-perceived-level-institutional-support-second-victim-after-patient-
safety-event
Clinicians involved
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psnet.ahrq.gov/node/37309/psn-pdf
January 05, 2012 - medication administration, and cardiovascular
agents and anticoagulants were the most common drug classes involved
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psnet.ahrq.gov/node/34778/psn-pdf
December 23, 2008 - The discussion continues by contrasting incidents and accidents and the cognitive processes
involved
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psnet.ahrq.gov/node/47411/psn-pdf
December 12, 2018 - Male physicians and those in procedural specialties were more likely
to be involved in an event involving
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psnet.ahrq.gov/node/45566/psn-pdf
October 19, 2016 - This
report reviews the results of the second round of funded effort, which involved more than 1500
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psnet.ahrq.gov/node/34811/psn-pdf
March 28, 2005 - Incorrect dosage represented the most common type of error, with antibiotics most frequently involved
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psnet.ahrq.gov/node/44772/psn-pdf
January 13, 2016 - post-event-debriefs-commitment-learning-how-better-care-patients-and-staff
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
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psnet.ahrq.gov/node/47200/psn-pdf
August 20, 2018 - The approach
involved the use of trigger tool technology, patient and family advisory councils, and
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psnet.ahrq.gov/node/34914/psn-pdf
February 27, 2009 - Discussion includes further categorization of the error types and exploration of the involved
factors
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psnet.ahrq.gov/node/44341/psn-pdf
July 22, 2015 - outcomes of
patients who underwent neurosurgery with only attending physicians versus those that also involved
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psnet.ahrq.gov/node/36122/psn-pdf
January 05, 2017 - In this case, the
MET conducted the initial resuscitation of the patient and was involved in coordinating
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psnet.ahrq.gov/node/37906/psn-pdf
July 16, 2008 - Morphine was the most common medication
involved.
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psnet.ahrq.gov/node/39298/psn-pdf
June 11, 2010 - error reporting system revealed that most
of the serious errors occurred during evening shifts and involved
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psnet.ahrq.gov/node/45271/psn-pdf
August 10, 2016 - This position paper draws from
international guidelines to advocate for standardizing the processes involved
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psnet.ahrq.gov/node/47213/psn-pdf
June 20, 2018 - are-second-victims-getting-help-they-need
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
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psnet.ahrq.gov/node/47159/psn-pdf
August 01, 2018 - safety-ii-behavior-pediatric-intensive-care-unit
The traditional approach to patient safety, frequently referred to as Safety-I, involved