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Showing results for "mechanism".

461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35729/psn-pdf
     May 08, 2018 - Pump up the volume—tips for increasing error reporting. May 8, 2018 ISMP Medication Safety Alert! Acute Care Edition. February 9, 2006;11:1-2,4. https://psnet.ahrq.gov/issue/pump-volume-tips-increasing-error-reporting This article presents best practices in six areas that can influence the success of incident repor…

462. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35864/psn-pdf
     June 17, 2014 - Exploring strategies for reducing hospital errors. June 17, 2014 McFadden KL, Stock GN, Gowen CR. Exploring strategies for reducing hospital errors. J Healthc Manag. 2006;51(2):123-136. https://psnet.ahrq.gov/issue/exploring-strategies-reducing-hospital-errors The authors surveyed health care quality directors on …

463. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38992/psn-pdf
     April 16, 2018 - Safe patient outcomes occur with timely, standardized communication of critical values. April 16, 2018 https://psnet.ahrq.gov/issue/safe-patient-outcomes-occur-timely-standardized-communication-critical- values This article reports on failures surrounding critical test results and describes mechanisms to standardi…

464. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39971/psn-pdf
     January 22, 2017 - Rapid response systems: from implementation to evidence base. January 22, 2017 Sarani B, Scott SD. Rapid response systems: from implementation to evidence base. Jt Comm J Qual Patient Saf. 2010;36(11):514-7, 481. https://psnet.ahrq.gov/issue/rapid-response-systems-implementation-evidence-base This commentary revi…

465. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43144/psn-pdf
     March 29, 2016 - Autopsy advocates. March 29, 2016 Clark C. HealthLeaders Media. April 11, 2014. https://psnet.ahrq.gov/issue/autopsy-advocates Highlighting how hospital autopsy programs can uncover diagnostic errors, reveal adverse events, and enhance learning opportunities, this news article recommends that these initiatives int…

466. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838175/psn-pdf
     September 28, 2022 - Modes of failure in venous thromboembolism prophylaxis. September 28, 2022 Richie CD, Castle JT, Davis GA, et al. Modes of failure in venous thromboembolism prophylaxis. Angiology. 2022;73(8):712-715. doi:10.1177/00033197221083724. https://psnet.ahrq.gov/issue/modes-failure-venous-thromboembolism-prophylaxis Hosp…

467. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47851/psn-pdf
     May 22, 2019 - Communication and Resolution After an Adverse Health Care Incident. May 22, 2019 Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201. https://psnet.ahrq.gov/issue/communication-and-resolution-after-adverse-health-care-incident Communication-and-resolution mechanisms are seen as important approache…

468. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39196/psn-pdf
     January 16, 2010 - Detecting adverse events in dermatologic surgery. January 16, 2010 Pinney D, Pearce DJ, Feldman SR. Detecting adverse events in dermatologic surgery. Dermatol Surg. 2010;36(1):8-14. doi:10.1111/j.1524-4725.2009.01378.x. https://psnet.ahrq.gov/issue/detecting-adverse-events-dermatologic-surgery This review identifi…

469. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39693/psn-pdf
     July 21, 2010 - Learning accountability for patient outcomes. July 21, 2010 Pronovost P. Learning accountability for patient outcomes. JAMA. 2010;304(2):204-5. doi:10.1001/jama.2010.979. https://psnet.ahrq.gov/issue/learning-accountability-patient-outcomes This commentary discusses efforts to reduce central line blood stream infe…

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39724/psn-pdf
     July 28, 2010 - Prone to error: earliest steps to find cancer. July 28, 2010 Saul S. New York Times. July 19, 2010;A1. https://psnet.ahrq.gov/issue/prone-error-earliest-steps-find-cancer This newspaper article investigates diagnostic errors in breast cancer through the story of a patient who was misdiagnosed. Concern about the ac…

471. DNR in the OR and Afterwards | PSNet
     psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
     July 01, 2003 - DNR in the OR and Afterwards Citation Text: Lo B. DNR in the OR and Afterwards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…

472. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37781/psn-pdf
     May 21, 2008 - Alcohol based surgical prep solution and the risk of fire in the operating room: a case report. May 21, 2008 Batra S, Gupta R. Alcohol based surgical prep solution and the risk of fire in the operating room: a case report. Patient Saf Surg. 2008;2(1):10. doi:10.1186/1754-9493-2-10. https://psnet.ahrq.gov/issue/alc…

473. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35595/psn-pdf
     January 04, 2009 - Patient Safety: Achieving a New Standard of Care. January 4, 2009 Institute of Medicine (US) Committee on Data Standards for Patient Safety, Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Washington (DC): National Academies Press (US); 2004. https://psnet.ahrq.gov/issue/patient-safety-achieving-new-standa…

474. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46494/psn-pdf
     January 24, 2018 - Complications. January 24, 2018 Anaesthesia. 2018;73(suppl 1):3-101. https://psnet.ahrq.gov/issue/complications Study of complications can provide insights into presurgical patient counseling, risk assessment, and medical harm prevention. Articles in this special issue explore complications in anesthesia, includin…

475. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41913/psn-pdf
     December 12, 2012 - Waking up the next morning: surgeons' emotional reactions to adverse events. December 12, 2012 Luu S, Patel P, St-Martin L, et al. Waking up the next morning: surgeons' emotional reactions to adverse events. Med Educ. 2012;46(12):1179-88. doi:10.1111/medu.12058. https://psnet.ahrq.gov/issue/waking-next-morning-sur…

476. Failure to utilize functions of an electronic prescribing system and the subsequent generation of 'technically preventable' computerized alerts. | PSNet
     psnet.ahrq.gov/issue/failure-utilize-functions-electronic-prescribing-system-and-subsequent-generation-technically
     February 15, 2012 - Study Failure to utilize functions of an electronic prescribing system and the subsequent generation of 'technically preventable' computerized alerts. Citation Text: Baysari M, Reckmann MH, Li L, et al. Failure to utilize functions of an electronic prescribing system and the subsequent g…

477. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39023/psn-pdf
     November 19, 2018 - Pediatric Readiness in the Emergency Department. November 19, 2018 Remick K, Gausche-Hill M, Joseph MM, et al. Pediatric Readiness in the Emergency Department. Pediatrics. 2018;142(5):e20182459. doi:10.1542/peds.2018-2459. https://psnet.ahrq.gov/issue/pediatric-readiness-emergency-department This revised set of gu…

478. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33956/psn-pdf
     March 07, 2005 - The Report of the Manitoba Pediatric Cardiac Surgery Inquest: An Inquiry into Twelve Deaths at the Winnipeg Health Sciences Center in 1994. March 7, 2005 Inquest, Manitoba Pediatric Cardiac Surgery. Winnepeg, Manitoba: Provincial Court of Manitoba; 1999. ISBN 0771115164. https://psnet.ahrq.gov/issue/report-manito…

479. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47050/psn-pdf
     April 18, 2018 - Improving Physician Well-Being, Restoring Meaning in Medicine. April 18, 2018 Accreditation Council for Graduate Medical Education. https://psnet.ahrq.gov/issue/physician-well-being Physician and resident well-being is receiving increased attention as an area of focus of the clinical learning environment. This we…

480. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43985/psn-pdf
     December 06, 2017 - Development of a medication safety and quality survey for small rural hospitals. December 6, 2017 Winterstein AG, Johns TE, Campbell KN, et al. Development of a Medication Safety and Quality Survey for Small Rural Hospitals. J Patient Saf. 2017;13(4):249-254. doi:10.1097/PTS.0000000000000154. https://psnet.ahrq.go…