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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42247/psn-pdf
    June 12, 2013 - multicenter-multidisciplinary-high-alert-medication-collaborative-improve- patient-safety This study involved
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36021/psn-pdf
    September 24, 2016 - The most frequent failures identified involved medications, orders, supplies, staffing, and equipment
  3. Psn-Pdf (pdf file)

    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
  4. Psn-Pdf (pdf file)

    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
  5. Psn-Pdf (pdf file)

    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
  6. Psn-Pdf (pdf file)

    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
  7. Psn-Pdf (pdf file)

    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
  8. Psn-Pdf (pdf file)

    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

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