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Showing results for "mechanism".

1521. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45370/psn-pdf
      July 27, 2016 - Correct use of inhalers: help patients breathe easier. July 27, 2016 ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6. https://psnet.ahrq.gov/issue/correct-use-inhalers-help-patients-breathe-easier Patients and clinicians can make medication administration mistakes when new drug delivery mecha…

1522. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46385/psn-pdf
      October 23, 2018 - The key to reducing doctors' misdiagnoses. October 23, 2018 Landro L. Wall Street Journal. September 12, 2017. https://psnet.ahrq.gov/issue/key-reducing-doctors-misdiagnoses Misdiagnosis has gained recognition as an important patient safety problem. This newspaper article reports on several areas of research and i…

1523. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45450/psn-pdf
      February 13, 2018 - Avoiding Unconscious Bias: a Guide for Surgeons. February 13, 2018 London, UK: Royal College of Surgeons of England; 2016. https://psnet.ahrq.gov/issue/avoiding-unconscious-bias-guide-surgeons Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides information for sur…

1524. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41896/psn-pdf
      December 12, 2012 - Bar-code verification: reducing but not eliminating medication errors. December 12, 2012 Henneman PL, Marquard J, Fisher DL, et al. Bar-code verification: reducing but not eliminating medication errors. J Nurs Adm. 2012;42(12):562-6. doi:10.1097/NNA.0b013e318274b545. https://psnet.ahrq.gov/issue/bar-code-verificat…

1525. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41391/psn-pdf
      May 30, 2012 - Overview of adverse events related to invasive procedures in the intensive care unit. May 30, 2012 Pottier V, Daubin C, Lerolle N, et al. Overview of adverse events related to invasive procedures in the intensive care unit. Am J Infect Control. 2012;40(3):241-6. doi:10.1016/j.ajic.2011.04.005. https://psnet.ahrq.g…

1526. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41588/psn-pdf
      August 15, 2012 - Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with trauma: a pilot study. August 15, 2012 Howie WO, Dutton RP. Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with trauma: a pilot study. AANA J. 2012;80(3):179-184…

1527. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49533/psn-pdf
      March 01, 2007 - However, the impact of such a reporting mechanism has not been confirmed in controlled studies, and

1528. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34726/psn-pdf
      April 19, 2011 - How house officers cope with their mistakes. April 19, 2011 Wu AW, Folkman S, McPhee SJ, et al. How house officers cope with their mistakes. West J Med. 1993;159(5):565-569. https://psnet.ahrq.gov/issue/how-house-officers-cope-their-mistakes In this article, the authors report on how house officers cope with their…

1529. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38472/psn-pdf
      March 11, 2009 - Feedback from incident reporting: information and action to improve patient safety. March 11, 2009 Benn J, Koutantji M, Wallace L, et al. Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care. 2009;18(1):11-21. doi:10.1136/qshc.2007.024166. https://psnet.ahrq.gov/…

1530. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43118/psn-pdf
      April 16, 2014 - NCPDP Recommendations and Guidance for Standardizing the Dosing Designations on Prescription Container Labels of Oral Liquid Medications Version 1.0. April 16, 2014 Scottsdale, AZ: National Council for Prescription Drug Programs; March 2014. https://psnet.ahrq.gov/issue/ncpdp-recommendations-and-guidance-standardi…

1531. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43018/psn-pdf
      March 19, 2014 - Improved obstetric safety through programmatic collaboration. March 19, 2014 Goffman D, Brodman M, Friedman AJ, et al. Improved obstetric safety through programmatic collaboration. J Healthc Risk Manag. 2014;33(3):14-22. doi:10.1002/jhrm.21131. https://psnet.ahrq.gov/issue/improved-obstetric-safety-through-program…

1532. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38508/psn-pdf
      March 25, 2009 - Supporting structures for team situation awareness and decision making: insights from four delivery suites. March 25, 2009 Mackintosh N, Berridge E-J, Freeth D. Supporting structures for team situation awareness and decision making: insights from four delivery suites. J Eval Clin Pract. 2009;15(1):46-54. doi:10.111…

1533. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39898/psn-pdf
      February 01, 2011 - Improving reliability of clinical care practices for ventilated patients in the context of a patient safety improvement initiative. February 1, 2011 Pinto A, Burnett S, Benn J, et al. Improving reliability of clinical care practices for ventilated patients in the context of a patient safety improvement initiative.…

1534. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36132/psn-pdf
      May 27, 2011 - Motion study in surgery. May 27, 2011 Gilbreth FB. Can J Med Surg. 1916:22-31. https://psnet.ahrq.gov/issue/motion-study-surgery This study was one of the first "time-motion" studies of physicians, and pioneered the application of human factors engineering and industrial principles to medical practice. The authors…

1535. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34929/psn-pdf
      April 06, 2011 - Implementing a national strategy for patient safety: lessons from the National Health Service in England. April 6, 2011 Lewis RQ, Fletcher M. Implementing a national strategy for patient safety: lessons from the National Health Service in England. Qual Saf Health Care. 2005;14(2):135-9. https://psnet.ahrq.gov/issu…

1536. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34744/psn-pdf
      January 07, 2019 - Judgment under Uncertainty: Heuristics and Biases. January 7, 2019 Kahneman D, Slovic P, Tversky A, eds. Cambridge, NY: Cambridge University Press; 1982. ISBN: 0521284147. https://psnet.ahrq.gov/issue/judgment-under-uncertainty-heuristics-and-biases Judgement is an inherently human activity tha…

1537. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39963/psn-pdf
      December 06, 2010 - Critical incident monitoring in paediatric and adult critical care: from reporting to improved patient outcomes? December 6, 2010 Frey B, Schwappach DLB. Critical incident monitoring in paediatric and adult critical care: from reporting to improved patient outcomes? Curr Opin Crit Care. 2010;16(6):649-53. doi:10.1…

1538. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47229/psn-pdf
      August 01, 2018 - The practice of respect in the ICU. August 1, 2018 Brown SM, Azoulay E, Benoit D, et al. The Practice of Respect in the ICU. Am J Respir Crit Care Med. 2018;197(11):1389-1395. doi:10.1164/rccm.201708-1676CP. https://psnet.ahrq.gov/issue/practice-respect-icu This commentary explores the results of a multidisciplina…

1539. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46213/psn-pdf
      June 28, 2017 - The second victim: a review. June 28, 2017 Coughlan B, Powell D, Higgins MF. The Second Victim: a Review. Eur J Obstet Gynecol Reprod Biol. 2017;213:11-16. doi:10.1016/j.ejogrb.2017.04.002. https://psnet.ahrq.gov/issue/second-victim-review Maternity care is a high-risk environment. This review discusses second vic…

1540. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34648/psn-pdf
      April 21, 2015 - Gaps in the continuity of care and progress on patient safety. April 21, 2015 Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ. 2000;320(7237):791-4. https://psnet.ahrq.gov/issue/gaps-continuity-care-and-progress-patient-safety This commentary discusses the concept o…