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psnet.ahrq.gov/issue/national-center-patient-safety-falls-toolkit-2004
May 24, 2017 - Conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues … January 1, 2022
System issues leading to "found-on-floor" incidents: a multi-incident
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psnet.ahrq.gov/issue/tamiflu-oseltamivir-oral-suspension-potential-medication-errors
November 07, 2012 - Issues a Voluntary Nationwide Recall of Atenolol 25 mg Tablets and Clopidogrel 75 mg Tablets Due to a … June 22, 2011
Hospira issues a voluntary nationwide recall for one lot of 0.5% Bupivacaine
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psnet.ahrq.gov/issue/relion-insulin-syringes-use-u-100-insulin-tyco-healthcare-covidien
September 30, 2015 - June 22, 2011
Hospira issues a voluntary nationwide recall for one lot of 0.5% Bupivacaine … June 28, 2023
Medication safety issues with newly authorized PAXLOVID.
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psnet.ahrq.gov/issue/important-warnings-and-instructions-heparin-sodium-injection-baxter
May 24, 2015 - May 24, 2015
Apotex Corp. issues voluntary nationwide recall of Enoxaparin Sodium Injection … June 22, 2011
Hospira issues a voluntary nationwide recall for one lot of 0.5% Bupivacaine
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psnet.ahrq.gov/issue/examining-increase-drug-shortages
March 01, 2017 - November 6, 2019
Oversight Hearing on Recent Patient Safety Issues. … May 1, 2015
Hearing on Patient Safety and Quality Issues in End Stage Renal Disease Treatment
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psnet.ahrq.gov/node/33738/psn-pdf
December 01, 2012 - You have to talk about these issues at the front end to get your
processes focused on safety. … I think it's one of the most
interesting cultural, process, and cognitive issues because we have such … There are other issues too. … They are starting to have people think about these issues in the design. … JR: If you take emerging technology, culture management issues, idealized process, and payment
reform—if
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psnet.ahrq.gov/node/49432/psn-pdf
February 09, 2004 - Errors never
occur in a vacuum: usually, system-based issues are contributing factors. … All of these issues must be addressed for residents to
successfully negotiate training. … If significant systems issues are
identified, then that information needs to be communicated to the … Too often, there is a disconnect between residency issues and the institutional quality
apparatus. … The format has enabled the identification of many systems issues that have subsequently been
improved
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psnet.ahrq.gov/node/33845/psn-pdf
November 01, 2017 - Many issues are less technological
and more policy and social issues. … It would be good to find ways that technologies could help make it easier for patients to flag issues … There are obviously challenges with important issues not getting triaged appropriately. … WP: It has been particularly useful for different gastrointestinal issues, irritable bowel diseases, … for looking at the microbiome as well, and that has strong
connections with these gastrointestinal issues
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - Non-emergency patient transport – what are the quality and safety issues? A systematic review. … Non-emergency patient transport – what are the quality and safety issues? A systematic review. … Non-emergency patient transport – what are the quality and safety issues? A systematic review. … Non-emergency patient transport – what are the quality and safety issues? A systematic review. … Non-emergency patient transport – what are the quality and safety issues? A systematic review.
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psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
September 01, 2014 - Although patients who lack insurance are at highest risk for these types of issues, merely having insurance … effectively advocate for themselves as they too may lack knowledge that would allow them to handle issues … It does not always have to be the physician who directly handles insurance or cost-related issues for … Improving the system requires educating patients and clinicians to identify cost-related medical issues … care systems should address this problem systematically, just as they do with other patient safety issues
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psnet.ahrq.gov/node/49693/psn-pdf
October 01, 2013 - Delineate patient safety issues associated with transgender health. … Transgender health raises a number of patient safety issues: lack of access to health care, increased … vulnerable and underserved part of the community, but they are also
at increased risk for a number of issues … Transitioning transgender individuals face a number of patient safety issues. … View AHRQ Disclaimers
http://transequality.org/Issues/homelessness.html
http://www.ncbi.nlm.nih.gov/
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.317_slideshow.ppt
March 01, 2014 - In: From Front Office to Front Line: Essential Issues for Health Care Leaders. 2nd ed. … In: From Front Office to Front Line: Essential Issues for Health Care Leaders. 2nd ed. … In: From Front Office to Front Line: Essential Issues for Health Care Leaders. 2nd ed. … Level 3: Disciplinary Intervention
Pattern persists
No change
Vast majority of professionals have no issues … Professional Accountability Pyramid (3)
When a pattern of misdiagnoses or related safety or quality issues
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.206_slideshow.ppt
October 01, 2009 - clinical facts
Contact chief of relevant service, involved providers
Must deal with immediate clinical issues … bad apples”
The CNO’s Perspective
Disrespectful, disruptive, hostile behavior remain significant issues … in “chain of command”
CMO acted promptly to deal with immediate clinical situation and behavioral issues
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psnet.ahrq.gov/issue/effective-followership-standardized-algorithm-resolve-clinical-conflicts-and-improve-teamwork
March 13, 2013 - Prevention in an Emergency Department Population: ED-SAFE
April 24, 2024
Cultural Issues … January 4, 2015
Using simulation to address hierarchy issues during medical crises.
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psnet.ahrq.gov/issue/what-do-nursing-students-learn-about-patient-safety-integrative-literature-review
October 15, 2016 - September 22, 2021
Ethical issues in patient safety: implications for nursing management … managers' and medical directors' perceptions of collaborating with patients concerning patient safety issues
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psnet.ahrq.gov/issue/compliance-technical-guidelines-radiotherapy-treatment-relation-patient-safety
December 10, 2014 - awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues … August 10, 2011
The use of human factors methods to identify and mitigate safety issues
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psnet.ahrq.gov/issue/phso-review-quality-nhs-complaints-investigations
November 16, 2015 - November 24, 2021
Report of the Independent Inquiry into the Issues Raised by Paterson … December 22, 2010
Adverse Events in Hospitals: Overview of Key Issues.
-
psnet.ahrq.gov/issue/health-care-associated-infections-hospitals-leadership-needed-hhs-prioritize-prevention
October 15, 2008 - January 22, 2014
Hearing on Patient Safety and Quality Issues in End Stage Renal Disease … April 15, 2009
Adverse Events in Hospitals: Overview of Key Issues.
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psnet.ahrq.gov/issue/drug-shortages-fdas-ability-respond-should-be-strengthened
April 15, 2009 - October 26, 2022
Oversight Hearing on Recent Patient Safety Issues. … October 1, 2014
Hearing on Patient Safety and Quality Issues in End Stage Renal Disease
-
psnet.ahrq.gov/issue/adverse-events-hospitals-care-study-incidence-among-medicare-beneficiaries-two-selected
January 14, 2009 - January 14, 2009
Adverse Events in Hospitals: Overview of Key Issues. … July 2, 2009
Adverse Events in Hospitals: Overview of Key Issues.