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9681. Leapfrog hospital safety scores 'depressing.' | PSNet
      psnet.ahrq.gov/issue/leapfrog-hospital-safety-scores-depressing
      November 13, 2013 - February 12, 2014 Reporting trends in a regional medication error data-sharing system

9682. Reducing Errors in Health Care: Translating Research Into Practice. | PSNet
      psnet.ahrq.gov/issue/reducing-errors-health-care-translating-research-practice
      October 23, 2019 - Fact Sheet/FAQs Reducing Errors in Health Care: Translating Research Into Practice. Citation Text: Reducing Errors in Health Care: Translating Research Into Practice. Rockville, MD: Agency of Healthcare Research and Quality; AHRQ Publication No. 00-PO58. Copy Citation S…

9683. Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality and readmission for patients with heart failure. | PSNet
      psnet.ahrq.gov/issue/relationship-between-hospital-adverse-events-and-hospital-performance-30-day-all-cause
      June 22, 2022 - Hospital Readmissions and Improve Health Outcomes March 29, 2023 Detectability of medication … errors with a STOPP/START-based medication review in older people prior to a potentially preventable

9684. Impact of fatigue on anaesthesia providers: a scoping review. | PSNet
      psnet.ahrq.gov/issue/impact-fatigue-anaesthesia-providers-scoping-review
      November 21, 2021 - with fatigue in anesthesia providers, including deterioration in non-technical skills, increased medication … errors, poor attention and psychomotor decline. … Related Resources WebM&M Cases Sleep Deprivation Leads to Medication … Error During Spinal Epidural Anesthesia August 30, 2023 Fatigue amongst anaesthesiology

9685. Fentora (fentanyl buccal tablet). | PSNet
      psnet.ahrq.gov/issue/fentora-fentanyl-buccal-tablet
      October 28, 2020 - Government Resource Fentora (fentanyl buccal tablet). Save Print Share Facebook Twitter Linkedin Copy URL September 26, 2007 This announcement provides specific instructions on safe prescribing of a cancer pain…

9686. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42954/psn-pdf
      December 04, 2016 - "Please describe from your point of view a typical case of an error in palliative care": qualitative data from an exploratory cross-sectional survey study among palliative care professionals. December 4, 2016 Dietz I, Plog A, Jox RJ, et al. "Please describe from your point of view a typical case of an error in pal…

9687. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866731/psn-pdf
      September 18, 2024 - Root cause analysis of cases involving diagnosis. September 18, 2024 Graber ML, Castro GM, Danforth M, et al. Root cause analysis of cases involving diagnosis. Diagnosis (Berl). 2024;11(4):353-368. doi:10.1515/dx-2024-0102. https://psnet.ahrq.gov/issue/root-cause-analysis-cases-involving-diagnosis Root cause analy…

9688. TeamSTEPPS Refresher Course. | PSNet
      psnet.ahrq.gov/issue/teamstepps-refresher-course
      September 26, 2023 - International Meeting/Conference TeamSTEPPS Refresher Course. Citation Text: AHA Training. October 3-24, 2023. Tuesdays 2:00 PM - 3:30 PM (eastern). Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin C…

9689. Bleeding Risk | PSNet
      psnet.ahrq.gov/web-mm/bleeding-risk
      November 01, 2003 - Medication errors specific to oral anticoagulants generally occur either due to inadequate monitoring … error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

9690. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37251/psn-pdf
      February 28, 2018 - Drug labeling and packaging — looking beyond what meets the eye. February 28, 2018 PA-PSRS Patient Safety Advisory. https://psnet.ahrq.gov/issue/drug-labeling-and-packaging-looking-beyond-what-meets-eye Drawing from data submitted to the Patient Safety Authority reporting system, this article documents factors in…

9691. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
      September 01, 2011 - Aspden P, Wolcott J, Bootman JL, Cronewett LR, eds for the Committee on Identifying and Preventing Medication … Errors, Institute of Medicine. … Preventing Medication Errors: Quality Chasm Series. … use)to assure appropriate management May also generate alerts when safety systems have failed (e.g., medication … error) In this case, such a report might have alerted staff about an increased pressure ulcer risk

9692. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45210/psn-pdf
      September 27, 2016 - Increased risk of burnout for physicians and nurses involved in a patient safety incident. September 27, 2016 Van Gerven E, Elst TV, Vandenbroeck S, et al. Increased Risk of Burnout for Physicians and Nurses Involved in a Patient Safety Incident. Med Care. 2016;54(10):937-943. doi:10.1097/MLR.0000000000000582. ht…

9693. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-423
      January 04, 2024 - January 17, 2024 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, report…

9694. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836978/psn-pdf
      May 16, 2022 - Check Twice, Transport Once May 16, 2022 DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/check-twice-transport-once The Case Case #1: A 26-year-old woman (Patient A) presented to the Emergency Department (ED) with abdominal pain and was diagnosed with “s…

9695. 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…

9696. Making Healthcare Safer III Report | PSNet
      psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
      March 30, 2020 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

9697. In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
      March 30, 2020 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

9698. Understanding nurses' and physicians' fear of repercussions for reporting errors: clinician characteristics, organization demographics, or leadership factors? | PSNet
      psnet.ahrq.gov/issue/understanding-nurses-and-physicians-fear-repercussions-reporting-errors-clinician
      October 13, 2021 - Associations of person-related, environment-related and communication-related factors on medication … errors in public and private hospitals: a retrospective clinical audit.

9699. Potential biases in machine learning algorithms using electronic health record data. | PSNet
      psnet.ahrq.gov/issue/potential-biases-machine-learning-algorithms-using-electronic-health-record-data
      June 12, 2019 - May 27, 2011 Preventing medication errors in hospitals through a systems approach and

9700. Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not? | PSNet
      psnet.ahrq.gov/issue/comparing-patient-reported-hospital-adverse-events-medical-record-review-do-patients-know
      February 03, 2011 - March 27, 2013 Physician patient communication failure facilitates medication errors