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Showing results for "learned".

  1. 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…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44625/psn-pdf
    November 20, 2015 - State-of-the-art usage of simulation in anesthesia: skills and teamwork. November 20, 2015 Krage R, Erwteman M. State-of-the-art usage of simulation in anesthesia: skills and teamwork. Curr Opin Anaesthesiol. 2015;28(6):727-34. doi:10.1097/ACO.0000000000000257. https://psnet.ahrq.gov/issue/state-art-usage-simulati…

  3. 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…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44024/psn-pdf
    October 13, 2015 - Cultivating a culture of medication safety in prelicensure nursing students. October 13, 2015 Bush PA, Hueckel RM, Robinson D, et al. Cultivating a Culture of Medication Safety in Prelicensure Nursing Students. Nurse Educ. 2015;40(4):169-73. doi:10.1097/NNE.0000000000000148. https://psnet.ahrq.gov/issue/cultivatin…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50428/psn-pdf
    September 04, 2019 - Patient safety incidents caused by poor quality surgical instruments. September 4, 2019 Dominguez ED, Rocos B. Patient Safety Incidents Caused by Poor Quality Surgical Instruments. Cureus. 2019;11(6):e4877. doi:10.7759/cureus.4877. https://psnet.ahrq.gov/issue/patient-safety-incidents-caused-poor-quality-surgical-…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851199/psn-pdf
    July 05, 2023 - Understanding the root cause analysis process to increase safety event reporting. July 5, 2023 Dudley KA. Understanding the root cause analysis process to increase safety event reporting. AORN J. 2023;117(6):399-402. doi:10.1002/aorn.13935. https://psnet.ahrq.gov/issue/understanding-root-cause-analysis-process-inc…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865719/psn-pdf
    May 01, 2024 - High reliability pediatric heart centers: always working toward getting better. May 1, 2024 Torzone A, Birely A. High reliability pediatric heart centers: always working toward getting better. Curr Opin Cardiol. 2024;39(4):356-363. doi:10.1097/hco.0000000000001143. https://psnet.ahrq.gov/issue/high-reliability-ped…

  8. 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…

  9. 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…

  10. 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…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44425/psn-pdf
    February 24, 2016 - Dangerous doses. February 24, 2016 Roe S, King K. Chicago Tribune. February 10–13, 2016. https://psnet.ahrq.gov/issue/dangerous-doses Drug interactions can be hazardous to patients, particularly when combined with risk factors such as age and use of medications for chronic conditions. This series of news reports d…

  12. 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…

  13. 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 …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46371/psn-pdf
    February 14, 2018 - Changing operating room culture: implementation of a postoperative debrief and improved safety culture. February 14, 2018 Magill ST, Wang DD, Rutledge C, et al. Changing Operating Room Culture: Implementation of a Postoperative Debrief and Improved Safety Culture. World Neurosurg. 2017;107:597-603. doi:10.1016/j.w…

  15. 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…

  16. 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…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44682/psn-pdf
    March 15, 2016 - On resident duty hour restrictions and neurosurgical training: review of the literature. March 15, 2016 Bina RW, Lemole M, Dumont TM. On resident duty hour restrictions and neurosurgical training: review of the literature. J Neurosurg. 2016;124(3):842-8. doi:10.3171/2015.3.JNS142796. https://psnet.ahrq.gov/issue/r…

  18. 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…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838141/psn-pdf
    September 21, 2022 - New Covid boosters look a lot like the old ones. Doctors worry that could lead to errors. September 21, 2022 Lovelace Jr, B. NBC News. September 7, 2022. https://psnet.ahrq.gov/issue/new-covid-boosters-look-lot-old-ones-doctors-worry-could-lead-errors Look-alike sound-alike packaging is a known risk factor in medi…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47843/psn-pdf
    March 06, 2019 - Structural iatrogenesis—a 43-year-old man with "opioid misuse." March 6, 2019 Stonington S, Coffa D. Structural Iatrogenesis - A 43-Year-Old Man with "Opioid Misuse". N Engl J Med. 2019;380(8):701-704. doi:10.1056/NEJMp1811473. https://psnet.ahrq.gov/issue/structural-iatrogenesis-43-year-old-man-opioid-misuse The…
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