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  1. Diagnostic Safety Toolkit. | PSNet

    psnet.ahrq.gov/issue/diagnostic-safety-toolkit
    December 05, 2024 - Toolkit Diagnostic Safety Toolkit. Citation Text: Child Health Patient Safety Organization. Diagnostic Safety Toolkit. Washington DC: Children's Hospital Association. May 2020. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

  2. Health Informatics, Healthcare Quality and Safety, and Healthcare Simulation: the New Triad to Advance Healthcare Operations | PSNet

    psnet.ahrq.gov/issue/health-informatics-healthcare-quality-and-safety-and-healthcare-simulation-new-triad-advance
    April 28, 2021 - Special or Theme Issue Health Informatics, Healthcare Quality and Safety, and Healthcare Simulation: the New Triad to Advance Healthcare Operations Citation Text: Health Informatics, Healthcare Quality and Safety, and Healthcare Simulation: the New Triad to Advance Healthcare Operations …

  3. Smart infusion pump investigations after an unexplained over-infusion. | PSNet

    psnet.ahrq.gov/issue/smart-infusion-pump-investigations-after-unexplained-over-infusion
    May 03, 2023 - Newspaper/Magazine Article Smart infusion pump investigations after an unexplained over-infusion. Citation Text: Smart infusion pump investigations after an unexplained over-infusion. ISMP Patient Safety Alert! Acute care edition. May 18, 2023;28(10);1-3. Copy Citation …

  4. Interruptions in healthcare: theoretical views. | PSNet

    psnet.ahrq.gov/issue/interruptions-healthcare-theoretical-views
    September 24, 2016 - Review Interruptions in healthcare: theoretical views. Citation Text: Grundgeiger T, Sanderson P. Interruptions in healthcare: theoretical views. Int J Med Inform. 2009;78(5):293-307. doi:10.1016/j.ijmedinf.2008.10.001. Copy Citation Format: DOI Google Scholar PubMed BibTeX…

  5. The Economics of Patient Safety: Strengthening a Value-based Approach to Reducing Patient Harm at National Level. | PSNet

    psnet.ahrq.gov/issue/economics-patient-safety-strengthening-value-based-approach-reducing-patient-harm-national
    May 02, 2018 - Book/Report The Economics of Patient Safety: Strengthening a Value-based Approach to Reducing Patient Harm at National Level. Citation Text: The Economics of Patient Safety: Strengthening a Value-based Approach to Reducing Patient Harm at National Level. Slawomirski L, Auraaen A, Klazing…

  6. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? | PSNet

    psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
    June 24, 2020 - April 29, 2018 NICU medication errors: identifying a risk profile for medication errors

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38118/psn-pdf
    October 01, 2019 - Preventing errors relating to commonly used anticoagulants. December 23, 2016 Preventing errors relating to commonly used anticoagulants. Sentinel Event Alert. 2008;41(41):1-4. https://psnet.ahrq.gov/issue/preventing-errors-relating-commonly-used-anticoagulants Anticoagulant therapies such as heparin and warfarin …

  8. Communication During Transitions of Care | PSNet

    psnet.ahrq.gov/perspective/communication-during-transitions-care
    July 10, 2024 - in healthcare are consistently reported as leading causes of preventable adverse events, including medication … errors and misdiagnosis. 1 It is widely recognized that communication , which can be defined as “the … errors, and misdiagnosis or delays in treatment. … study published in 2023 identified ineffective communication as a key contributor to high rates of medication … errors when transitioning patients from the ICU to the general medical ward.

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43193/psn-pdf
    June 17, 2014 - Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis. June 17, 2014 Manrique-Rodríguez S, Sánchez-Galindo AC, López-Herce J, et al. Risks in the implementation and use of smart pumps in a pediatric intensive care unit: applicati…

  10. The Anesthesia Patient Safety Foundation at 25: a pioneering success in safety, 25th anniversary provokes reflection, anticipation. | PSNet

    psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation-25-pioneering-success-safety-25th-anniversary-provokes
    January 01, 2015 - Commentary The Anesthesia Patient Safety Foundation at 25: a pioneering success in safety, 25th anniversary provokes reflection, anticipation. Citation Text: Eichhorn JH. The Anesthesia Patient Safety Foundation at 25: a pioneering success in safety, 25th anniversary provokes reflection,…

  11. Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-miss surgical events. | PSNet

    psnet.ahrq.gov/issue/duke-surgery-patient-safety-open-source-application-anonymous-reporting-adverse-and-near-miss
    February 15, 2011 - Commentary Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-miss surgical events. Citation Text: Pietrobon R, Lima R, Shah A, et al. Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-mi…

  12. Reportable incidents. | PSNet

    psnet.ahrq.gov/issue/reportable-incidents
    November 02, 2016 - Newspaper/Magazine Article Reportable incidents. Citation Text: Barishansky RM, Glick DE. Reportable incidents. Establishing policies and procedures for when calls go wrong. EMS magazine. 2009;38(3):43-7. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML End…

  13. Tubing misconnections: normalization of deviance. | PSNet

    psnet.ahrq.gov/issue/tubing-misconnections-normalization-deviance
    December 16, 2015 - Review Tubing misconnections: normalization of deviance. Citation Text: Simmons D, Symes L, Guenter P, et al. Tubing misconnections: normalization of deviance. Nutr Clin Pract. 2011;26(3):286-293. doi:10.1177/0884533611406134. Copy Citation Format: DOI Google Scholar PubM…

  14. Infusing fun into quality and safety initiatives. | PSNet

    psnet.ahrq.gov/issue/infusing-fun-quality-and-safety-initiatives
    October 19, 2022 - Commentary Infusing fun into quality and safety initiatives. Citation Text: Foulk KC, Tocydlowski P, Snow TM, et al. Infusing fun into quality and safety initiatives. Nursing (Brux). 2012;42(11):14-16. doi:10.1097/01.NURSE.0000421386.36112.a9. Copy Citation Format: DOI Goo…

  15. A review of educational philosophies as applied to radiation safety training at medical institutions. | PSNet

    psnet.ahrq.gov/issue/review-educational-philosophies-applied-radiation-safety-training-medical-institutions
    May 31, 2017 - Commentary A review of educational philosophies as applied to radiation safety training at medical institutions. Citation Text: Dauer LT, St Germain J. A review of educational philosophies as applied to radiation safety training at medical institutions. Health Phys. 2006;90(5 Suppl):S6…

  16. Applying the Toyota Production System: using a patient safety alert system to reduce error. | PSNet

    psnet.ahrq.gov/issue/applying-toyota-production-system-using-patient-safety-alert-system-reduce-error
    June 21, 2015 - Commentary Applying the Toyota Production System: using a patient safety alert system to reduce error. Citation Text: Furman C, Caplan RA. Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf. 2007;33(7):376-386. Copy …

  17. Simulation for operational readiness in a new freestanding emergency department: strategy and tactics. | PSNet

    psnet.ahrq.gov/issue/simulation-operational-readiness-new-freestanding-emergency-department-strategy-and-tactics
    August 20, 2018 - Study Simulation for operational readiness in a new freestanding emergency department: strategy and tactics. Citation Text: Kerner RL, Gallo K, Cassara M, et al. Simulation for Operational Readiness in a New Freestanding Emergency Department. Simul Healthc. 2016;11(5). doi:10.1097/sih.00…

  18. Learning from malpractice claims about negligent, adverse events in primary care in the United States. | PSNet

    psnet.ahrq.gov/issue/learning-malpractice-claims-about-negligent-adverse-events-primary-care-united-states
    April 07, 2011 - Study Learning from malpractice claims about negligent, adverse events in primary care in the United States. Citation Text: Phillips RL, Bartholomew LA, Dovey S, et al. Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Healt…

  19. Management of the difficult airway: a closed claims analysis. | PSNet

    psnet.ahrq.gov/issue/management-difficult-airway-closed-claims-analysis
    July 13, 2010 - Study Management of the difficult airway: a closed claims analysis. Citation Text: Peterson GN, Domino KB, Caplan RA, et al. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005;103(1):33-39. Copy Citation Format: Google Scholar PubMed BibTeX…

  20. Cognitive Systems Engineering in Health Care. | PSNet

    psnet.ahrq.gov/issue/cognitive-systems-engineering-health-care
    October 11, 2016 - Book/Report Cognitive Systems Engineering in Health Care. Citation Text: Cognitive Systems Engineering in Health Care. Bisantz AM, Burns CM, Fairbanks RJ, eds. Boca Raton, FL: CRC Press; 2014. ISBN: 9781466587960. Copy Citation Save Save to your library Prin…
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