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2821. Signout Fallout | PSNet
      psnet.ahrq.gov/web-mm/signout-fallout
      November 16, 2022 - SPOTLIGHT CASE Signout Fallout Citation Text: Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…

2822. In Conversation With… Thomas J. Nasca, MD, MACP | PSNet
      psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
      July 10, 2024 - In Conversation With… Thomas J. Nasca, MD, MACP April 1, 2016  Citation Text: In Conversation With… Thomas J. Nasca, MD, MACP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citat…

2823. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73526/psn-pdf
      July 28, 2021 - Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. July 28, 2021 Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions The Case …

2824. Duplicate Insulin Order | PSNet
      psnet.ahrq.gov/web-mm/duplicate-insulin-order
      May 04, 2012 - Duplicate Insulin Order Citation Text: Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

2825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846170/psn-pdf
      March 15, 2023 - Duplicate Therapies in Retail Pharmacy March 15, 2023 Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy The Cases Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection f…

2826. The Empty Bag | PSNet
      psnet.ahrq.gov/web-mm/empty-bag
      June 01, 2018 - The Empty Bag Citation Text: Vincent C. The Empty Bag. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

2827. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49822/psn-pdf
      March 01, 2018 - Isolated Clot, Real Error March 1, 2018 Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/isolated-clot-real-error Case Objectives Appreciate that errors are common in the management of venous thromboembolism disease. Describe patients with venous thromboembolism i…

2828. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33580/psn-pdf
      April 01, 2022 - Nursing and Patient Safety April 21, 2021 Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. PSNet [internet]. 2021. https://psnet.ahrq.gov/primer/nursing-and-patient-safety Updated in March 2021. Originally published in December 2011 by researchers at the University of California, San Francisco.  …

2829. When Things Go Wrong: Voices of Patients and Families. | PSNet
      psnet.ahrq.gov/issue/when-things-go-wrong-voices-patients-and-families
      November 19, 2015 - Audiovisual When Things Go Wrong: Voices of Patients and Families. Citation Text: When Things Go Wrong: Voices of Patients and Families. CRICO/RMF; Harvard Risk Management Foundation Copy Citation Save Save to your library Print Download PDF Shar…

2830. Being open: communicating patient safety incidents with patients and their carers. | PSNet
      psnet.ahrq.gov/issue/being-open-communicating-patient-safety-incidents-patients-and-their-carers
      October 26, 2007 - Multi-use Website Being open: communicating patient safety incidents with patients and their carers. Citation Text: Being open: communicating patient safety incidents with patients and their carers. National Patient Safety Agency. Copy Citation Save Save to your l…

2831. Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention. | PSNet
      psnet.ahrq.gov/issue/patients-and-families-teachers-mixed-methods-assessment-collaborative-learning-model-medical
      July 12, 2017 - Study Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention. Citation Text: Langer T, Martinez W, Browning DM, et al. Patients and families as teachers: a mixed methods assessment of a collaborative lea…

2832. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41051/psn-pdf
      February 20, 2012 - What do patients and relatives know about problems and failures in care? February 20, 2012 Iedema R, Allen S, Britton K, et al. What do patients and relatives know about problems and failures in care? BMJ Qual Saf. 2012;21(3):198-205. doi:10.1136/bmjqs-2011-000100. https://psnet.ahrq.gov/issue/what-do-patients-and…

2833. An Untimely End Despite End-of-Life Care Planning | PSNet
      psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
      February 01, 2012 - by the nurse in charge of the patient, and all the involved teams are expected to have at least one member

2834. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42535/psn-pdf
      October 16, 2013 - Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members. October 16, 2013 Jeffs L, Abramovich IA, Hayes C, et al. Implementing an interprofessional patient safety learning initiative: insights from participants, project leads an…

2835. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40275/psn-pdf
      March 23, 2011 - Discrepant perceptions of communication, teamwork and situation awareness among surgical team members. March 23, 2011 Wauben LSGL, van Doorn CMD-, van Wijngaarden JDH, et al. Discrepant perceptions of communication, teamwork and situation awareness among surgical team members. Int J Qual Health Care. 2011;23(2):15…

2836. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49423/psn-pdf
      November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…

2837. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47555/psn-pdf
      November 14, 2018 - How one hospital improved patient safety in 10 minutes a day. November 14, 2018 van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018. https://psnet.ahrq.gov/issue/how-one-hospital-improved-patient-safety-10-minutes-day Aviation continues to provide inspiration for patient safety innovation. This commentar…

2838. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34839/psn-pdf
      April 06, 2011 - Communication failures in the operating room: an observational classification of recurrent types and effects. April 6, 2011 Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5):330-4. http…

2839. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45031/psn-pdf
      February 18, 2017 - Information transfer in multidisciplinary operating room teams: a simulation-based observational study. February 18, 2017 Cumin D, Skilton C, Weller J. Information transfer in multidisciplinary operating room teams: a simulation- based observational study. BMJ Qual Saf. 2017;26(3):209-216. doi:10.1136/bmjqs-2015-00…

2840. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42638/psn-pdf
      October 09, 2013 - Strengths and weaknesses of working with the Global Trigger Tool method for retrospective record review: focus group interviews with team members. October 9, 2013 Schildmeijer K, Nilsson L, Perk J, et al. Strengths and weaknesses of working with the Global Trigger Tool method for retrospective record review: focus…