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effectivehealthcare.ahrq.gov/get-involved/nominated-topics/self-measured-blood-pressure-monitoringMarch 12, 2009 - Home » Get Involved » Nominated Topics » Topic Suggestion Description Topic Suggestion Description Date submitted: March 12, 2009 Download Topic Suggestion Disposition [PDF · 191 KB] Briefly describe a specific question, or set of related questions, about a health ca…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35569/psn-pdfApril 29, 2018 - Fatal misadministration of IV vincristine. April 29, 2018 ISMP Medication Safety Alert! Acute care edition. December 1, 2005 https://psnet.ahrq.gov/issue/fatal-misadministration-iv-vincristine This alert responds to fatal medication errors involving vincristine and reiterates the importance of adhering to error re… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35194/psn-pdfDecember 09, 2008 - Drug errors, qualitative research and some reflections on ethics. December 9, 2008 Armitage G. Drug errors, qualitative research and some reflections on ethics. J Clin Nurs. 2005;14(7):869- 75. https://psnet.ahrq.gov/issue/drug-errors-qualitative-research-and-some-reflections-ethics In this position paper, the au… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36918/psn-pdfSeptember 01, 2011 - Developing a culture of safety in ambulatory care settings. September 1, 2011 Shostek K. Developing a culture of safety in ambulatory care settings. J Ambul Care Manage. 2007;30(2):105-13. https://psnet.ahrq.gov/issue/developing-culture-safety-ambulatory-care-settings The author discusses the issues involved in e… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36351/psn-pdfOctober 27, 2010 - When the bone flap hits the floor. October 27, 2010 Jankowitz BT, Kondziolka DS. When the bone flap hits the floor. Neurosurgery. 2006;59(3):585-90; discussion 585-90. https://psnet.ahrq.gov/issue/when-bone-flap-hits-floor The authors discuss the incidence, treatment, and outcomes of cases involving errors that co… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39041/psn-pdfOctober 21, 2009 - The OR and a "just culture." October 21, 2009 Hamlin L. The OR and a "just culture". AORN J. 2009;90(4):495-498. doi:10.1016/j.aorn.2009.09.003. https://psnet.ahrq.gov/issue/or-and-just-culture To illustrate the value of just culture implementation, this piece describes a hypothetical scenario involving the WHO Sa… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37720/psn-pdfJune 13, 2011 - Deploying med reconciliation. June 13, 2011 Williams T, Acton C, Hicks RW. Deploying med reconciliation. Nurs Manage. 2008;39(4):54-7. doi:10.1097/01.NUMA.0000316062.73435.f4. https://psnet.ahrq.gov/issue/deploying-med-reconciliation This commentary describes how one medical center developed a medication reconcili… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37579/psn-pdfFebruary 27, 2008 - Rx for errors: speed, high volume can trigger mistakes. February 27, 2008 McCoy K; Brady E. https://psnet.ahrq.gov/issue/rx-errors-speed-high-volume-can-trigger-mistakes This series of investigative articles uncovers the factors involved in pharmacy errors, relates stories of patients harmed by such errors, and in… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38580/psn-pdfApril 22, 2009 - Practising safely in the foundation years. April 22, 2009 Long SJ, Neale G, Vincent CA. Practising safely in the foundation years. BMJ. 2009;338:b1046. doi:10.1136/bmj.b1046. https://psnet.ahrq.gov/issue/practising-safely-foundation-years Through case scenarios, this commentary examines adverse events involving ju… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39367/psn-pdfApril 16, 2018 - Medication errors with the dosing of insulin: problems across the continuum. April 16, 2018 PA-PSRS Patient Saf Advis. March 2010;7:9-17. https://psnet.ahrq.gov/issue/medication-errors-dosing-insulin-problems-across-continuum This article analyzed 2685 event reports involving insulin and found that the most common… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42813/psn-pdfDecember 04, 2016 - Patient Stories 2013: Time for Change. December 4, 2016 Harrow, Middlesex, UK: The Patients Association; 2013. https://psnet.ahrq.gov/issue/patient-stories-2013-time-change This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36776/psn-pdfAugust 26, 2011 - The role of the chief executive officer in maximizing patient safety. August 26, 2011 Shorr AS. The role of the chief executive officer in maximizing patient safety. Healthcare executive. 2007;22(2):20-2, 24, 26. https://psnet.ahrq.gov/issue/role-chief-executive-officer-maximizing-patient-safety The author discus… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41882/psn-pdfNovember 28, 2012 - What is the NHS Safety Thermometer? November 28, 2012 Power M, Stewart K, Brotherton A. What is the NHS Safety Thermometer? Clin Risk. 2012;18(5):163-169. https://psnet.ahrq.gov/issue/what-nhs-safety-thermometer This commentary describes the design and initial test of a large-scale initiative to track incidents inv… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38789/psn-pdfJuly 28, 2013 - AMA meeting: delegates see boosting quality of care as duty. July 28, 2013 O'Reilly KB. American Medical News. July 6, 2009;17:28. https://psnet.ahrq.gov/issue/ama-meeting-delegates-see-boosting-quality-care-duty This news article reviews the American Medical Association's new policy designed to involve physicians… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35160/psn-pdfJanuary 02, 2017 - Unlabeled containers lead to patient's death. January 2, 2017 Cohen MR, Smetzer JL. Unlabeled containers lead to patient's death. Jt Comm J Qual Patient Saf. 2005;31(7):414-7. https://psnet.ahrq.gov/issue/unlabeled-containers-lead-patients-death The authors review selected incidents of harm involving unlabeled con… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35974/psn-pdfMay 08, 2018 - Tablet splitting: Do it only if you "half" to, and then do it safely. May 8, 2018 ISMP Medication Safety Alert! Acute Care Edition. May 18, 2006;11:1-2. https://psnet.ahrq.gov/issue/tablet-splitting-do-it-only-if-you-half-and-then-do-it-safely This alert presents the risks involved with tablet splitting and outlin… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34631/psn-pdfDecember 23, 2016 - Sentinel Event Alert. December 23, 2016 Oakbrook Terrace, IL: The Joint Commission. https://psnet.ahrq.gov/issue/sentinel-event-alert This newsletter provides guidance to health care organizations for responding to commonly reported incidents. The Joint Commission issues these sentinel event alerts to review selec… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40831/psn-pdfOctober 05, 2011 - 'Alarm fatigue’ a factor in 2nd death. October 5, 2011 Kowalczyk L. Boston Globe. September 21, 2011. https://psnet.ahrq.gov/issue/alarm-fatigue-factor-2nd-death Reporting on a patient death involving alarm fatigue, this newspaper article describes how one hospital adopted aggressive measures to prevent sim… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35171/psn-pdfDecember 19, 2018 - Measuring Patient Safety. December 19, 2018 Newhouse R, Poe S. Sudbury, MA: Jones and Bartlett Publishers; 2005. ISBN 9780763728410. https://psnet.ahrq.gov/issue/measuring-patient-safety This book provides nurses with the concepts and processes involved in improving patient safety. From discussion of safety princi… -
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-finalreport-update-2021.pdfJanuary 01, 2021 - Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care: Final Report Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care Final Report This page is intentionally blank. Potentially Preventable Readmissions: Conceptual Framewo…
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