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Showing results for "learned".

5921. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44888/psn-pdf
      April 06, 2016 - Transforming the morbidity and mortality conference to promote safety and quality in a PICU. April 6, 2016 Cifra CL, Bembea MM, Fackler JC, et al. Transforming the morbidity and mortality conference to promote safety and quality in a PICU. Crit Care Med. 2016;17(1):58-66. doi:10.1097/PCC.0000000000000539. https://…

5922. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60969/psn-pdf
      November 08, 2023 - Network of Patient Safety Databases Chartbook. November 8, 2023 Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23- 0082. https://psnet.ahrq.gov/issue/network-patient-safety-databases-chartbook The sharing of data is a core element of a learning health system. AHRQ h…

5923. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837630/psn-pdf
      July 06, 2022 - Mandating limits on workload, duty, and speed in radiology. July 6, 2022 Alexander R, Waite S, Bruno MA, et al. Mandating limits on workload, duty, and speed in radiology. Radiology. 2022:212631. doi:10.1148/radiol.212631. https://psnet.ahrq.gov/issue/mandating-limits-workload-duty-and-speed-radiology To reduce m…

5924. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45188/psn-pdf
      June 01, 2016 - Reporting and second-order problem solving can turn short-term fixes into long-term remedies. June 1, 2016 ISMP Medication Safety Alert! Acute Care Edition. May 19, 2016;21:1-4. https://psnet.ahrq.gov/issue/reporting-and-second-order-problem-solving-can-turn-short-term-fixes-long- term-remedies Workarounds are pr…

5925. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43686/psn-pdf
      November 26, 2014 - Tools for primary care patient safety: a narrative review. November 26, 2014 Spencer R, Campbell S. Tools for primary care patient safety: a narrative review. BMC Fam Pract. 2014;15:166. doi:10.1186/1471-2296-15-166. https://psnet.ahrq.gov/issue/tools-primary-care-patient-safety-narrative-review Proven methods to …

5926. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44749/psn-pdf
      December 27, 2018 - Southern Baptist Hospital of Florida v. Charles. December 27, 2018 Fla Ct App, 1st Dist. October 28, 2015. https://psnet.ahrq.gov/issue/southern-baptist-hospital-florida-v-charles The Patient Safety and Quality Improvement Act (PSQIA) provides federal protection of adverse event reports voluntarily submitted to pa…

5927. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37344/psn-pdf
      March 28, 2012 - Introduction of an obstetric-specific medical emergency team for obstetric crises: implementation and experience. March 28, 2012 Gosman GG, Baldisseri MR, Stein KL, et al. Introduction of an obstetric-specific medical emergency team for obstetric crises: implementation and experience. Am J Obstet Gynecol. 2008;198(…

5928. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838030/psn-pdf
      September 07, 2022 - Rethinking use of air-safety principles to reduce fatal hospital errors. September 7, 2022 Rethinking use of air-safety principles to reduce fatal hospital errors. doi:10.1377/forefront.20220824.965364. https://psnet.ahrq.gov/issue/rethinking-use-air-safety-principles-reduce-fatal-hospital-errors The safety of co…

5929. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43647/psn-pdf
      November 12, 2014 - Mid Staffordshire NHS Foundation Trust Quality Report. November 12, 2014 Newcastle Upon Tyne, UK: Care Quality Commission; October 9, 2014. https://psnet.ahrq.gov/issue/mid-staffordshire-nhs-foundation-trust-quality-report The Mid Staffordshire Trust has been under much scrutiny in recent years. This report highlig…

5930. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43459/psn-pdf
      August 27, 2014 - Serious Reportable Events. August 27, 2014 Nova Scotia Department of Health and Wellness. https://psnet.ahrq.gov/issue/serious-reportable-events Incident reporting systems are an important method for capturing, analyzing, and learning about a broad range of potential safety issues. This Web site provides access to…

5931. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45143/psn-pdf
      October 20, 2016 - Medical improv: a novel approach to teaching communication and professionalism skills. October 20, 2016 Watson K, Fu B. Medical Improv: A Novel Approach to Teaching Communication and Professionalism Skills. Ann Intern Med. 2016;165(8):591-592. doi:10.7326/M15-2239. https://psnet.ahrq.gov/issue/medical-improv-novel…

5932. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60034/psn-pdf
      March 11, 2020 - Responding to unprofessional behavior by trainees - a "just culture" framework. March 11, 2020 Wasserman JA, Redinger M, Gibb T. Responding to Unprofessional Behavior by Trainees — A “Just Culture” Framework. New England Journal of Medicine. 2020;382(8). doi:10.1056/nejmms1912591. https://psnet.ahrq.gov/issue/resp…

5933. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40606/psn-pdf
      October 31, 2011 - The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units. October 31, 2011 Pastores SM, O'Connor MF, Kleinpell R, et al. The Accreditation Council for Graduate Medical Education resident duty hour new standards: hist…

5934. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73185/psn-pdf
      April 28, 2021 - Balancing patient safety, clinical efficacy, and cybersecurity with clinician partners. April 28, 2021 Schneider J, Wirth A. Balancing patient safety, clinical efficacy, and cybersecurity with clinician partners. Biomed Instrum Technol. 2021;55(1):21-28. doi:10.2345/0899-8205-55.1.21. https://psnet.ahrq.gov/issue/…

5935. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854832/psn-pdf
      October 25, 2023 - Achieving a successful patient safety program with implementation of a harm reduction strategy. October 25, 2023 Cohen JB. APSF Newsletter. 2023;38(10):93-95. https://psnet.ahrq.gov/issue/achieving-successful-patient-safety-program-implementation-harm-reduction- strategy Zero harm, while a laudable goal, has been…

5936. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46564/psn-pdf
      December 06, 2017 - Can the aviation industry be useful in teaching oncology about safety? December 6, 2017 Davies JM, Delaney G. Can the Aviation Industry be Useful in Teaching Oncology about Safety? Clin Oncol (R Coll Radiol). 2017;29(10):669-675. doi:10.1016/j.clon.2017.06.007. https://psnet.ahrq.gov/issue/can-aviation-industry-be…

5937. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837211/psn-pdf
      May 25, 2022 - 4 actions to reduce medical errors in U.S. hospitals. May 25, 2022 Toussaint JS, Segel KT. Harvard Business Review. April 20, 2022. https://psnet.ahrq.gov/issue/4-actions-reduce-medical-errors-us-hospitals The patient safety movement has had mixed results in sustaining improvement and commitment. This comment…

5938. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38099/psn-pdf
      October 01, 2008 - Decreased bile duct injury rate during laparoscopic cholecystectomy in the era of the 80-hour resident workweek. October 1, 2008 Yaghoubian A, Saltmarsh G, Rosing DK, et al. Decreased bile duct injury rate during laparoscopic cholecystectomy in the era of the 80-hour resident workweek. Arch Surg. 2008;143(9):847-5…

5939. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44781/psn-pdf
      January 13, 2016 - Improving Pediatric Surgery Quality and Outcomes in the 21st Century. January 13, 2016 Heiss K, ed. Semin Pediatr Surg. 2015;24:265-326. https://psnet.ahrq.gov/issue/improving-pediatric-surgery-quality-and-outcomes-21st-century Articles in this special issue introduce quality improvement principles, such as system…

5940. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852803/psn-pdf
      August 23, 2023 - Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. August 23, 2023 Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. Jt Comm J Qual Patient Saf. 2023;49(12):724-729. doi:10.1016/j.jcjq.2023.07.006. https://psnet.ahrq.gov/issue/sentinel-event-alert-67-preserving-patient-sa…