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Showing results for "issues".

401. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39709/psn-pdf
     September 20, 2011 - of such conferences with presentation of cases and expert commentaries discussing relevant safety issues … systems audit framework that was applied to M&M conferences to enhance resident awareness of systems issues

402. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37032/psn-pdf
     May 27, 2011 - The studies also provided only limited information on implementation issues and potential unintended … Such issues will need to be addressed in order to improve the slow pace of uptake of CPOE in US hospitals

403. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42473/psn-pdf
     August 13, 2013 - As the majority of equipment problems were due to potentially preventable issues (such as equipment … Preoperative time outs are also an effective means of prospectively identifying potential equipment issues

404. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37843/psn-pdf
     March 04, 2011 - problems and facility design problems as major contributors to errors, with staffing and communication issues … These human factors issues contribute to latent errors, and the authors suggest that equipment and facility

405. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45715/psn-pdf
     November 01, 2017 - care, executive walk rounds are used to help senior leadership engage in discussions about safety issues … Leaders reported that participating in walk rounds increased their awareness around safety issues and

406. Radiation Safety | PSNet
     psnet.ahrq.gov/primer/radiation-safety
     September 15, 2024 - This Patient Safety Primer will discuss the safety issues associated with the use of radiation, both … occur with radiotherapy usually arise from multiple causes and are attributable to underlying systems issues … These issues may be exacerbated by the use of different software programs and varying types of radiotherapy … training with new equipment, poor interoperability of systems, and other human factors engineering issues … Current Context Like all issues that have been the subject of Sentinel Event Alerts, radiation safety

407. In Conversation with… Michael Cohen, RPh, MS, ScD (hon) | PSNet
     psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
     April 01, 2006 - with the practitioner, and we can contact the FDA, JCAHO, or even product vendors if broader product issues … , packaging issues, and even nomenclature issues. … I walk into some community pharmacies, and the management just hasn't caught up to the safety issues. … Why is this so, and how can we incorporate safety issues in our curricula in ways that better prepare … Second, pharmacists themselves often draw perimeters around their sphere of influence to include issues

408. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43571/psn-pdf
     October 01, 2014 - executives or senior managers visiting frontline staff and engaging in conversations about potential safety issues … i-think-we-should-just-listen-and-get-out-qualitative-exploration-views-and-experiences https://psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program

409. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45536/psn-pdf
     October 05, 2016 - clinician-identified-problems-and-solutions-delayed-diagnosis-primary-care- prioritize-study Compared with other patient safety issues … The main issues included inability to meet patients' care needs and inadequate communication between

410. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42502/psn-pdf
     October 07, 2013 - statement from the American Heart Association (AHA) reviews the current state of knowledge on safety issues … which are considered the standard of care for cardiac patients, have traditionally focused on clinical issues

411. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33758/psn-pdf
     December 01, 2013 - and NIH and is now a nationally recognized expert in electronic health record–related patient safety issues … around technology, electronic medical records, issues around trainees. … Let's say you weren't fundamentally interested in IT-related safety issues, but you see a huge federal … We were doing work on EHR-related safety issues including missed test results for many years before … And some of my ventures into IT-type safety issues were built nicely on our previous sociotechnical

412. Spotlight (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
     January 01, 2019 - as an opportunity to broadly consider not only medical complications but all of the patient safety issues … Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in … Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in … Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in … * This Case Hypoxia, persistent tachycardia, and inability to cooperate were red flags These issues

413. Patient Safety in Office-Based Care Settings | PSNet
     psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
     January 31, 2024 - But challenges in office-based care settings, such as falls, diagnostic issues, and complications related … That analysis attempted to make an overall account of the kinds of safety issues that arise in office-based … Clinician-reported non-routine events included case delays from machine failures and staffing issues. … Follow-up and follow-through on the patient’s health and health issues are key to building trust and … , you have more eyes on that patient and a better capacity to identify potential safety issues before

414. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33631/psn-pdf
     April 01, 2006 - Why is this so, and how can we incorporate safety issues in our curricula in ways that better prepare … Second, pharmacists themselves often draw perimeters around their sphere of influence to include issues … the full medication use process (eg, optimal medication ordering/dispensing systems and regulatory issues … disease management in community settings, they may expect to meet resistance.(10) Addressing these issues … only a small but thoughtful broadening of our offerings to raise the awareness of our students to the issues

415. Training Education | PSNet
     psnet.ahrq.gov/training-education
     October 01, 2025 - Read More Have you encountered medical errors or patient safety issues … Have you encountered medical errors or patient safety issues?

416. Home | PSNet
     psnet.ahrq.gov/
     March 25, 2025 - Primary Care Surgery Sign up for PSNet Issues … Read More Have you encountered medical errors or patient safety issues … Have you encountered medical errors or patient safety issues?

417. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33584/psn-pdf
     March 15, 2025 - Issues involving communication between clinicians at times of transitions in care are discussed in the … The Joint Commission has found that communication issues are the most common root cause of sentinel … More subtle issues, such as nonverbal cues, interpersonal relations, and group dynamics, can affect

418. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37363/psn-pdf
     February 03, 2011 - Generalizing the results from positive RRT outcome studies is often limited by methodological issues … An accompanying editorial [link below] discusses these issues and the implications of this study for

419. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
     January 01, 2024 - 13 Communication Issues (1) Most notably, this patient’s team experienced a breakdown in communication … compression—all problems that potentially require immediate intervention. 14 14 Communication Issues … management of such findings are all good routine communication practices.3 16 16 Communication Issues … Issues related to the impact of EHR usability, copy-and-paste notes, and autopopulated text are discussed … Patient Safety Issues From Information Overload in Electronic Medical Records. 

420. Accidental exposures to fentanyl patches continue to be deadly to children. | PSNet
     psnet.ahrq.gov/issue/fentanyl-patch-can-be-deadly-children
     January 13, 2021 - March 4, 2015 Hospira issues a voluntary nationwide recall for one lot of 0.5% Bupivacaine … May 19, 2021 Apotex Corp. issues voluntary nationwide recall of Enoxaparin Sodium Injection