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8961. Development of "SWARM" as a model for high reliability, rapid problem solving, and institutional learning. | PSNet
      psnet.ahrq.gov/issue/development-swarm-model-high-reliability-rapid-problem-solving-and-institutional-learning
      November 16, 2022 - Commentary Development of "SWARM" as a model for high reliability, rapid problem solving, and institutional learning. Citation Text: Williams EA, Nikolai DA, Ladwig L, et al. Development of "SWARM" as a Model for High Reliability, Rapid Problem Solving, and Institutional Learning. Jt Com…

8962. Operating-room fire at hospital burns patient, prompts changes. | PSNet
      psnet.ahrq.gov/issue/operating-room-fire-hospital-burns-patient-prompts-changes
      September 21, 2022 - Newspaper/Magazine Article Operating-room fire at hospital burns patient, prompts changes. Citation Text: Operating-room fire at hospital burns patient, prompts changes. Natt TM Jr. The Pilot. August 9, 2013. Copy Citation Save Save to your library Pri…

8963. Consumer Guide to Adverse Health Events. | PSNet
      psnet.ahrq.gov/issue/consumer-guide-adverse-health-events
      June 04, 2024 - Book/Report Consumer Guide to Adverse Health Events. Citation Text: Consumer Guide to Adverse Health Events. St Paul, MN: Minnesota Department of Health; 2015. Copy Citation Save Save to your library Print Download PDF Share Facebook …

8964. Developing an adverse event reporting system using administrative data. | PSNet
      psnet.ahrq.gov/issue/developing-adverse-event-reporting-system-using-administrative-data
      September 23, 2009 - Study Developing an adverse event reporting system using administrative data. Citation Text: Developing an adverse event reporting system using administrative data. Bahl V; Thompson MA; Commisky EL; Anderson S; Campbell DA Jr. Copy Citation Save Save to your …

8965. Recurrent Hypoglycemia: A Care Transition Failure? | PSNet
      psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
      December 23, 2020 - May 27, 2011 Medication errors with the use of allopurinol and colchicine: a retrospective

8966. Patient Safety. | PSNet
      psnet.ahrq.gov/issue/patient-safety-25
      December 14, 2022 - 2022 Use of complete medication history to identify and correct transitions-of-care medication … errors at psychiatric hospital admission.

8967. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45595/psn-pdf
      April 19, 2017 - triggers-and-trigger-tools https://psnet.ahrq.gov/primer/never-events https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events

8968. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42361/psn-pdf
      September 19, 2013 - engaging-patient-observer-promote-hand-hygiene-compliance-ambulatory-care https://psnet.ahrq.gov/issue/medication-errors-home-multisite-study-children-cancer

8969. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47079/psn-pdf
      July 02, 2019 - decision support systems are widely utilized to improve patient safety by alerting providers to potential medication … errors and other safety concerns.

8970. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36723/psn-pdf
      July 26, 2011 - prescribing-safely-children The authors describe challenges in prescribing medications for children, including common medication … errors and adverse drug reactions.

8971. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36033/psn-pdf
      June 21, 2006 - infants-risk-when-nurse-fatigue-jeopardizes-quality-care The authors discuss nurse fatigue and present two case studies of medication … errors committed by tired nurses to illustrate its impact on neonatal intensive care unit (NICU) care

8972. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness | PSNet
      psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
      February 01, 2014 - They concluded that each interruption results in a 12.7% increased risk of a medication error and that … individually and collectively, to ensure that they actually do reduce the frequency and severity of medication … errors without negative unanticipated consequences.( 5 ) Certain clinical environments such as the … errors ( 14 ) or interruptions.( 2 ) The adoption of this strategy appears somewhat limited perhaps … Keep away: Kaiser South San Francisco RNs don yellow sashes to reduce interruptions and medication errors

8973. The effect of hospital electronic health record adoption on nurse-assessed quality of care and patient safety. | PSNet
      psnet.ahrq.gov/issue/effect-hospital-electronic-health-record-adoption-nurse-assessed-quality-care-and-patient
      March 28, 2012 - Related Resources How effective are electronic medication systems in reducing medication … error rates and associated harm among hospital inpatients?

8974. Interorganizational health information exchange-related patient safety incidents: a descriptive register-based qualitative study. | PSNet
      psnet.ahrq.gov/issue/interorganizational-health-information-exchange-related-patient-safety-incidents-descriptive
      November 10, 2021 - May 22, 2024 Enhanced free-text search for aggregated medication error report analysis

8975. Implementing patient and family involvement interventions for promoting patient safety: a systematic review and meta-analysis. | PSNet
      psnet.ahrq.gov/issue/implementing-patient-and-family-involvement-interventions-promoting-patient-safety-systematic
      February 02, 2022 - February 10, 2021 How effective are electronic medication systems in reducing medication … error rates and associated harm among hospital inpatients?

8976. Listen to me, I really am sick! Patient and family narratives of clinical deterioration before and during rapid response system intervention. | PSNet
      psnet.ahrq.gov/issue/listen-me-i-really-am-sick-patient-and-family-narratives-clinical-deterioration-and-during
      June 25, 2018 - January 4, 2012 Use of an audit with feedback implementation strategy to promote medication … error reporting by nurses.

8977. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41349/psn-pdf
      May 02, 2012 - Patient Safety Papers 6. May 2, 2012 Baker GR, ed. Healthc Q. 2012;15:1-72. https://psnet.ahrq.gov/issue/patient-safety-papers-6 This special issue exploring patient safety in Canada highlights topics such as teamwork, medication reconciliation, and diagnostic error. https://psnet.ahrq.gov/issue/patient-safety-pa…

8978. Patient safety practices: leaders can turn barriers into accelerators. | PSNet
      psnet.ahrq.gov/issue/patient-safety-practices-leaders-can-turn-barriers-accelerators
      September 07, 2011 - October 6, 2011 Economic impact of medication error: a systematic review.

8979. Engaging Physicians in Teamwork Training for Quality and Safety - Or Why Don’t Your Physicians Get Engaged? | PSNet
      psnet.ahrq.gov/issue/engaging-physicians-teamwork-training-quality-and-safety-or-why-dont-your-physicians-get
      July 21, 2021 - May 12, 2021 Enhancing Your Medication Error Reporting Program to Improve Global Medication

8980. Considering human factors and developing systems-thinking behaviours to ensure patient safety. | PSNet
      psnet.ahrq.gov/issue/considering-human-factors-and-developing-systems-thinking-behaviours-ensure-patient-safety
      March 01, 2023 - Newspaper/Magazine Article Considering human factors and developing systems-thinking behaviours to ensure patient safety. Citation Text: Considering human factors and developing systems-thinking behaviours to ensure patient safety. Vosper H; Lim R; Knight C; et al; CIEHF Pharmaceutical H…