-
psnet.ahrq.gov/node/42247/psn-pdf
June 12, 2013 - multicenter-multidisciplinary-high-alert-medication-collaborative-improve-
patient-safety
This study involved
-
psnet.ahrq.gov/node/36021/psn-pdf
September 24, 2016 - The most frequent failures identified involved medications,
orders, supplies, staffing, and equipment
-
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/39174/psn-pdf
December 16, 2009 - review of incident reports found more than 100
cases in a 5-year period in which parents were directly involved
-
psnet.ahrq.gov/node/39501/psn-pdf
January 03, 2017 - Of the 300,000 medication events
reported, approximately 4% involved heparin products, with the administration
-
psnet.ahrq.gov/node/45060/psn-pdf
January 01, 2017 - patients undergoing
upper endoscopy, there was an increased rate of serious adverse events in cases that involved
-
psnet.ahrq.gov/node/46496/psn-pdf
October 11, 2017 - adverse-events-near-misses-and-errors
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
-
psnet.ahrq.gov/node/45697/psn-pdf
August 29, 2018 - distance of the liability insurer from the site of care, and a lack of trust among
the organizations involved