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Showing results for "learned".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73691/psn-pdf
    September 08, 2021 - Pump up the volume: tips for increasing error reporting and decreasing patient harm. September 8, 2021 ISMP Medication Safety Alert! Acute care edition. August 26, 2021;26(17);1-5.  https://psnet.ahrq.gov/issue/pump-volume-tips-increasing-error-reporting-and-decreasing-patient-harm Error reporting is an essen…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39051/psn-pdf
    November 04, 2009 - On the prospects for a blame-free medical culture. November 4, 2009 Collins ME, Block SD, Arnold RM, et al. On the prospects for a blame-free medical culture. Soc Sci Med. 2009;69(9):1287-90. doi:10.1016/j.socscimed.2009.08.033. https://psnet.ahrq.gov/issue/prospects-blame-free-medical-culture This study found tha…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851461/psn-pdf
    July 19, 2023 - Patient safety 2.0: slaying dragons, not just investigating them. July 19, 2023 Card AJ. Patient safety 2.0: slaying dragons, not just investigating them. J Patient Saf. 2023;19(6):394-395. doi:10.1097/pts.0000000000001140. https://psnet.ahrq.gov/issue/patient-safety-20-slaying-dragons-not-just-investigating-them …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46071/psn-pdf
    March 20, 2018 - Evaluating situation awareness: an integrative review. March 20, 2018 Orique SB, Despins L. Evaluating Situation Awareness: An Integrative Review. West J Nurs Res. 2018;40(3):388-424. doi:10.1177/0193945917697230. https://psnet.ahrq.gov/issue/evaluating-situation-awareness-integrative-review Situation awareness in…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41802/psn-pdf
    October 31, 2012 - Relationship between high-fidelity simulation and patient safety in prelicensure nursing education: a comprehensive review. October 31, 2012 Blum CA, Parcells DA. Relationship between high-fidelity simulation and patient safety in prelicensure nursing education: a comprehensive review. J Nurs Educ. 2012;51(8):429-…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46005/psn-pdf
    July 11, 2018 - The 2016 John M. Eisenberg Patient Safety and Quality Awards. July 11, 2018 Jt Comm J Qual Patient Saf. 2017;43:315-337. https://psnet.ahrq.gov/issue/2016-john-m-eisenberg-patient-safety-and-quality-awards Spotlighting the accomplishments of the 2016 recipients of the John M. Eisenberg Patient Safety and Quality …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41406/psn-pdf
    August 02, 2012 - Can patients report patient safety incidents in a hospital setting? A systematic review. August 2, 2012 Ward JK, Armitage G. Can patients report patient safety incidents in a hospital setting? A systematic review. BMJ Qual Saf. 2012;21(8):685-99. doi:10.1136/bmjqs-2011-000213. https://psnet.ahrq.gov/issue/can-pati…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46461/psn-pdf
    November 01, 2017 - Complications: acknowledging, managing, and coping with human error. November 1, 2017 Helo S, Moulton C-AE. Complications: acknowledging, managing, and coping with human error. Transl Androl Urol. 2017;6(4):773-782. doi:10.21037/tau.2017.06.28. https://psnet.ahrq.gov/issue/complications-acknowledging-managing-and-…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74108/psn-pdf
    January 01, 2022 - 'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors. November 24, 2021 Klasen JM, Teunissen PW, Driessen EW, et al. ‘It depends’: the complexity of allowing residents to fail from the perspective of clinical supervisors. Med Teach. 2022;44(2):196-205. doi:10.1080…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44087/psn-pdf
    November 16, 2015 - Teaching a 'good' ward round. November 16, 2015 Powell N, Bruce CG, Redfern O. Teaching a 'good' ward round. Clin Med (Lond). 2015;15(2):135-138. doi:10.7861/clinmedicine.15-2-135. https://psnet.ahrq.gov/issue/teaching-good-ward-round Ward rounds, while an important educational activity, may not receive the attent…

  11. Anesthesiology Control Tower: Feedback Alerts to Supplement Treatment (ACTFAST) - Final Report | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/anesthesiology-control-tower-feedback-alerts-supplement-treatment-actfast/final-report
    January 01, 2023 - Anesthesiology Control Tower: Feedback Alerts to Supplement Treatment (ACTFAST) - Final Report Citation Avidan M. Anesthesiology Control Tower: Feedback Alerts to Supplement Treatment (ACTFAST) - Final Report. (Prepared by the University of Utah under Grant No. R21 HS024581). Rockville, MD: Agency for…

  12. Optimal Methods for Notifying Clinicians About Epilepsy Surgery Patients - Final Report | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/optimal-methods-notifying-clinicians-about-epilepsy-surgery-patients/final-report
    January 01, 2023 - Optimal Methods for Notifying Clinicians About Epilepsy Surgery Patients - Final Report Citation Dexheimer J. Optimal Methods for Notifying Clinicians About Epilepsy Surgery Patients - Final Report. (Prepared by Cincinnati Children's Hospital Medical Center under Grant No. R21 HS024977). Rockville, MD…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34759/psn-pdf
    July 13, 2016 - Human Error. July 13, 2016 Reason JT. Cambridge, UK: Cambridge University Press; 1990. ISBN: 9780521306690. https://psnet.ahrq.gov/issue/human-error Despite writing almost nothing specifically on health care, clinical psychologist James Reason has influenced modern thinking about medical errors more than any other…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46105/psn-pdf
    May 01, 2022 - AORN Position Statement on Patient Safety. May 1, 2022 AORN Position Statement on Patient Safety. AORN J. 2022;115(5):454-457. doi:10.1002/aorn.13671. https://psnet.ahrq.gov/issue/aorn-position-statement-patient-safety This position statement outlines recommendations from the Association of periOperative Registered…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45111/psn-pdf
    May 11, 2016 - Educational opportunities with postevent debriefing. May 11, 2016 Mullan PC, Kessler DO, Cheng A. Educational opportunities with postevent debriefing. JAMA. 2014;312(22):2333-4. doi:10.1001/jama.2014.15741. https://psnet.ahrq.gov/issue/educational-opportunities-postevent-debriefing Real-time or near real-time lear…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47944/psn-pdf
    April 17, 2019 - How to deliver safer and effective patient care: tips for team leaders and educators. April 17, 2019 Shah BJ. How to Deliver Safer and Effective Patient Care: Tips for Team Leaders and Educators. Gastroenterology. 2019;156(4):852-855. doi:10.1053/j.gastro.2019.02.017. https://psnet.ahrq.gov/issue/how-deliver-safer…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44291/psn-pdf
    September 13, 2016 - A piece of my mind. I'm sorry. September 13, 2016 Kahn JS. A PIECE OF MY MIND. I'm Sorry. JAMA. 2015;313(24):2427-8. doi:10.1001/jama.2014.6507. https://psnet.ahrq.gov/issue/piece-my-mind-im-sorry Being accountable for errors and working to learn from them is key to improving patient safety. This commentary descri…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73992/psn-pdf
    October 20, 2021 - Mix-ups between the influenza (Flu) vaccine and COVID- 19 vaccines. October 20, 2021 ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4. https://psnet.ahrq.gov/issue/mix-ups-between-influenza-flu-vaccine-and-covid-19-vaccines Production pressure and low staff coverage can result in medica…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838192/psn-pdf
    September 28, 2022 - When medical error becomes personal, activism becomes painful. September 28, 2022 Millenson M. Forbes. September 16, 2022. https://psnet.ahrq.gov/issue/when-medical-error-becomes-personal-activism-becomes-painful Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm w…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867601/psn-pdf
    January 22, 2025 - AI: promise or peril for patient safety. January 22, 2025 Ullem BD, Hatlie MJ, Lounsbury O. AI: promise or peril for patient safety. J Patient Saf. 2025;21(1):34-37. doi:10.1097/pts.0000000000001301. https://psnet.ahrq.gov/issue/ai-promise-or-peril-patient-safety Patients for Patient Safety US (PFPS-US) is a patie…
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