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Total Results: 1,802 records

Showing results for "mechanism".

441. Mobility Lost in the ICU | PSNet
     psnet.ahrq.gov/web-mm/mobility-lost-icu
     August 01, 2018 - SPOTLIGHT CASE Mobility Lost in the ICU Citation Text: Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…

442. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50902/psn-pdf
     February 12, 2020 - Improving care by using patient feedback. February 12, 2020 National Institute for Health Research. Southampton, UK: NIHR Dissemination Centre; December 2019. https://psnet.ahrq.gov/issue/improving-care-using-patient-feedback Patient feedback is a problematic source of patient safety improvement information. This r…

443. Impact of organizational culture on preventability assessment of selected adverse events in the ICU: evaluation of morbidity and mortality conferences. | PSNet
     psnet.ahrq.gov/issue/impact-organizational-culture-preventability-assessment-selected-adverse-events-icu
     August 15, 2016 - Study Impact of organizational culture on preventability assessment of selected adverse events in the ICU: evaluation of morbidity and mortality conferences. Citation Text: Pelieu I, Djadi-Prat J, Consoli SM, et al. Impact of organizational culture on preventability assessment of selec…

444. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/860400/psn-pdf
     January 10, 2024 - AHA Patient Safety Initiative. January 10, 2024 American Hospital Association. https://psnet.ahrq.gov/issue/aha-patient-safety-initiative Leadership at the organization and system level is crucial to gaining improvement traction and sustainability. This initiative centers on safety culture, care inequities, and wo…

445. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49752/psn-pdf
     January 01, 2016 - Inadvertent Use of More Potent Acid Leads to Burn January 1, 2016 Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn The Case A 31-year-old woman came to the clinic for a routine well-woman evaluation. She…

446. Hierarchy and medical error: speaking up when witnessing an error. | PSNet
     psnet.ahrq.gov/issue/hierarchy-and-medical-error-speaking-when-witnessing-error
     April 14, 2011 - Review Emerging Classic Hierarchy and medical error: speaking up when witnessing an error. Citation Text: Peadon R (R), Hurley J, Hutchinson M. Hierarchy and medical error: speaking up when witnessing an error. Safety Sci. 2020;125:104648. doi:10.1016/j.ssci.202…

447. Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery. | PSNet
     psnet.ahrq.gov/issue/evaluation-electronic-health-record-structured-discharge-summary-provide-real-time-adverse
     December 29, 2014 - Study Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery. Citation Text: Graham AJ, Ocampo W, Southern DA, et al. Evaluation of an electronic health record structured discharge summary to provide real ti…

448. National Patient Safety Foundation agenda for research and development in patient safety. | PSNet
     psnet.ahrq.gov/issue/national-patient-safety-foundation-agenda-research-and-development-patient-safety
     June 16, 2011 - Commentary Classic National Patient Safety Foundation agenda for research and development in patient safety. Citation Text: Cooper JB, Gaba DM, Liang B, et al. The National Patient Safety Foundation agenda for research and development in patient safety. MedGenMe…

449. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39540/psn-pdf
     February 17, 2011 - Disconnected. February 17, 2011 Klass P. Disconnected. N Engl J Med. 2010;362(15):1358-61. doi:10.1056/NEJMp0911193. https://psnet.ahrq.gov/issue/disconnected This narrative illustrates potential dangers and delays that may result from inadequate confirmation of contact mechanisms and protocols for patient follow-…

450. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45495/psn-pdf
     January 01, 2021 - Medical students raising concerns. October 12, 2016 Druce MR, Hickey A, Warrens AN, et al. Medical Students Raising Concerns. J Patient Saf. 2021;17(5):e367-e372. https://psnet.ahrq.gov/issue/medical-students-raising-concerns A key aspect of safety culture is that all team members feel comfortable with raising saf…

451. Crossing the Line | PSNet
     psnet.ahrq.gov/web-mm/crossing-line
     December 01, 2012 - SPOTLIGHT CASE Crossing the Line Citation Text: Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…

452. Pseudo-obstruction But a Real Perforation | PSNet
     psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
     April 01, 2015 - SPOTLIGHT CASE Pseudo-obstruction But a Real Perforation Citation Text: Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: …

453. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/855104/psn-pdf
     November 08, 2023 - Healthcare wants to fly as high as the aviation industry. Can it? November 8, 2023 Twenter P. Becker's Clinical Leadership. October 30, 2023. https://psnet.ahrq.gov/issue/healthcare-wants-fly-high-aviation-industry-can-it Health care has long held commercial aviation as a beacon to guide patient safety improv…

454. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50606/psn-pdf
     October 30, 2019 - One doctor. 25 deaths. How could it have happened? October 30, 2019 Healy J, Farr I, Feiger L, Duffy C. New York Times. October 11, 2019. https://psnet.ahrq.gov/issue/one-doctor-25-deaths-how-could-it-have-happened Systemic failures persistently undermine processes meant to keep patients safe. This news story discu…

455. Drug-drug interactions and actual harm to hospitalized patients: a multicentre study examining the prevalence pre- and post-electronic medication system implementation. | PSNet
     psnet.ahrq.gov/issue/drug-drug-interactions-and-actual-harm-hospitalized-patients-multicentre-study-examining
     August 26, 2020 - Study Drug-drug interactions and actual harm to hospitalized patients: a multicentre study examining the prevalence pre- and post-electronic medication system implementation. Citation Text: Li L, Baker J, Quirk R, et al. Drug-drug interactions and actual harm to hospitalized patients: a …

456. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/845079/psn-pdf
     February 22, 2023 - Pump up the volume: how to prioritize events and analyze error data. February 22, 2023 ISMP Medication Safety Alert! Acute care edition. February 9, 2023;28(3):1-4. https://psnet.ahrq.gov/issue/pump-volume-how-prioritize-events-and-analyze-error-data Patient safety event reporting is an established component of a …

457. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35970/psn-pdf
     August 10, 2010 - Chemotherapy error: practical approaches to increasing patient safety. August 10, 2010 Harris TJ, Northfelt DW. Chemotherapy Error. J Patient Saf. 2008;1(4). doi:10.1097/01.jps.0000215340.80935.d0. https://psnet.ahrq.gov/issue/chemotherapy-error-practical-approaches-increasing-patient-safety The authors present a…

458. Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study. | PSNet
     psnet.ahrq.gov/issue/effects-two-commercial-electronic-prescribing-systems-prescribing-error-rates-hospital
     September 01, 2016 - Study Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study. Citation Text: Westbrook JI, Reckmann MH, Li L, et al. Effects of two commercial electronic prescribing systems on prescribing error rates in hos…

459. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73970/psn-pdf
     October 21, 2021 - The Good, The Bad, and The Ugly: Patient Experiences with CRPs. October 13, 2021 Collaborative for Accountability and Improvement. October 21, 2021.  https://psnet.ahrq.gov/issue/good-bad-and-ugly-patient-experiences-crps Communication-and-resolution program (CRP) initiatives are a valuable strategy for impro…

460. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837339/psn-pdf
     June 08, 2022 - Mindful workarounds in bar code medication administration. June 8, 2022 Lichtner V, Dowding D. Mindful workarounds in bar code medication administration. Stud Health Technol Inform. 2022;294:740-744. doi:10.3233/shti220575. https://psnet.ahrq.gov/issue/mindful-workarounds-bar-code-medication-administration Barcod…