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1321. The co-design, implementation and evaluation of a serious board game 'PlayDecide patient safety' to educate junior doctors about patient safety and the importance of reporting safety concerns | PSNet
      psnet.ahrq.gov/issue/co-design-implementation-and-evaluation-serious-board-game-playdecide-patient-safety-educate
      September 12, 2018 - September 12, 2018 The Collective Leadership for Safety Culture (Co-Lead) team intervention

1322. Situational (Un)Awareness | PSNet
      psnet.ahrq.gov/web-mm/situational-unawareness
      August 01, 2009 - The Commentary Medication errors are the most frequent type of medical error and can lead to significant … Research by Ash and colleagues found that implementation of CPOE can lead to overdependence on technology

1323. Dangerous Dapsone | PSNet
      psnet.ahrq.gov/web-mm/dangerous-dapsone
      January 10, 2011 - care.( 7 ) Data on cisapride dispensing further confirms that a lack of environmental control may lead … Communication problems may lead to errors.

1324. Building a Safety Program Using Principles of Resilience Engineering | PSNet
      psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
      October 23, 2013 - However, a push for efficiency can lead to unanticipated effects on safety, as resources (such as staff … For instance, the push for maximizing operating room (OR) utilization can sometimes lead OR coordinators

1325. Beware of basal opioid infusions with PCA therapy. | PSNet
      psnet.ahrq.gov/issue/beware-basal-opioid-infusions-pca-therapy
      June 05, 2018 - Newspaper/Magazine Article Beware of basal opioid infusions with PCA therapy. Citation Text: Beware of basal opioid infusions with PCA therapy. ISMP Medication Safety Alert! Acute Care Edition. March 12, 2009;14:1-3. Copy Citation Save Save to your library P…

1326. Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition. | PSNet
      psnet.ahrq.gov/issue/lean-hospitals-improving-quality-patient-safety-and-employee-engagement-third-edition
      May 04, 2016 - Book/Report Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition. Citation Text: Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition. Graban M. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781498743259. Copy…

1327. Rethinking Patient Safety. | PSNet
      psnet.ahrq.gov/issue/rethinking-patient-safety
      April 13, 2018 - Book/Report Rethinking Patient Safety. Citation Text: Rethinking Patient Safety. Woodward S. Boca Raton, FL: Productivity Press; 2017. ISBN: 9781498778541. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitte…

1328. Editorial Team | PSNet
      psnet.ahrq.gov/Information/Editor
      Barnes is the physician lead for a bold initiative to bring AHRQ's TeamSTEPPS program to all physicians … Roslyn has previously served as associate lead for quality and supported projects across 3 urban emergency

1329. Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. | PSNet
      psnet.ahrq.gov/issue/engineering-patient-safety-radiation-oncology-university-north-carolinas-pursuit-high
      May 04, 2016 - Book/Report Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. Citation Text: Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. M…

1330. Education outcomes from a duty-hour flexibility trial in internal medicine. | PSNet
      psnet.ahrq.gov/issue/education-outcomes-duty-hour-flexibility-trial-internal-medicine
      December 12, 2012 - August 2, 2015 Did duty hour reform lead to better outcomes among the highest risk patients

1331. Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics. | PSNet
      psnet.ahrq.gov/issue/missed-diagnoses-acute-myocardial-infarction-emergency-department-variation-patient-and
      April 08, 2018 - 2018 WebM&M Cases Missing ECG and Missed Diagnosis Lead

1332. The ongoing quality improvement journey: next stop, high reliability. | PSNet
      psnet.ahrq.gov/issue/ongoing-quality-improvement-journey-next-stop-high-reliability
      January 23, 2012 - Commentary The ongoing quality improvement journey: next stop, high reliability. Citation Text: Chassin MR, Loeb JM. The ongoing quality improvement journey: next stop, high reliability. Health Aff (Millwood). 2011;30(4):559-68. doi:10.1377/hlthaff.2011.0076. Copy Citation Format…

1333. Good Night's Sleep Gone Wrong | PSNet
      psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
      September 01, 2015 - pharmacokinetics of many medications change due to slower metabolism and decreased clearance, which can lead … electronic provider order entry systems with insomnia orders sets to guide clinical decision-making may lead

1334. Emergency department visits for antibiotic-associated adverse events. | PSNet
      psnet.ahrq.gov/issue/emergency-department-visits-antibiotic-associated-adverse-events
      October 31, 2014 - Study Emergency department visits for antibiotic-associated adverse events. Citation Text: Shehab N, Patel PR, Srinivasan A, et al. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis. 2008;47(6):735-43. doi:10.1086/591126. Copy Citation Format: …