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psnet.ahrq.gov/node/45337/psn-pdf
August 15, 2016 - Nurse workload and inexperienced medical staff members
are associated with seasonal peaks in severe adverse
events in the adult medical intensive care unit: a seven-
year prospective study.
August 15, 2016
Faisy C, Davagnar C, Ladiray D, et al. Nurse workload and inexperienced medical staff members are
associated…
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psnet.ahrq.gov/node/43068/psn-pdf
May 29, 2014 - Patient safety incidents in home hospice care: the
experiences of hospice interdisciplinary team members.
May 29, 2014
Smucker DR, Regan S, Elder NC, et al. Patient safety incidents in home hospice care: the experiences of
hospice interdisciplinary team members. J Palliat Med. 2014;17(5):540-4. doi:10.1089/jpm.2013…
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - Midwestern community hospital found that 97% of respondents had provided a medical service for a family member … Zuger has declared that neither she, nor any immediate member of her family, has a financial arrangement … The line between physician and family member. Ann Intern Med. 2008;149:825-829.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - Example of Highly Reliable Organization
Achieving safety on flight decks of aircraft carriers
Any member
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psnet.ahrq.gov/node/73427/psn-pdf
June 23, 2021 - Incidence and OR team awareness of “near-miss” and
retained surgical sharps: a national survey on United
States operating rooms.
June 23, 2021
Weprin SA, Meyer D, Li R, et al. Incidence and OR team awareness of “near-miss” and retained surgical
sharps: a national survey on United States operating rooms. Patient Sa…
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - therapy candidate is one who can self-administer IV medications at home or with the help of a family member … patients selected for home infusion OPAT must be taught to self-administer or asked to identify a family member … patient needs to have an established support system after discharge, which typically includes a household member
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psnet.ahrq.gov/issue/patients-and-family-members-views-how-clinicians-enact-and-how-they-should-enact-incident
September 29, 2017 - Study
Patients' and family members' views on how clinicians enact and how they should enact incident disclosure: the "100 patient stories" qualitative study.
Citation Text:
Iedema R, Allen S, Britton K, et al. Patients' and family members' views on how clinicians enact and how they shoul…
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psnet.ahrq.gov/node/35611/psn-pdf
June 23, 2010 - Error or "act of God"? A study of patients' and operating
room team members' perceptions of error definition,
reporting, and disclosure.
June 23, 2010
Espin S, Levinson W, Regehr G, et al. Error or "act of God"? A study of patients' and operating room team
members' perceptions of error definition, reporting, and d…
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psnet.ahrq.gov/issue/introductions-during-time-outs-do-surgical-team-members-know-one-anothers-names
November 09, 2015 - Study
Introductions during time-outs: do surgical team members know one another's names?
Citation Text:
Birnbach DJ, Rosen LF, Fitzpatrick M, et al. Introductions during time-outs: do surgical team members know one another's names? Jt Comm J Qual Patient Saf. 2017;43(6):284-288. doi:10.1…
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psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
January 01, 2020 - therapy candidate is one who
can self-administer IV medications at home or with the help of
a family member
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psnet.ahrq.gov/issue/health-plan-members-views-about-disclosure-medical-errors
November 15, 2011 - Study
Classic
Health plan members' views about disclosure of medical errors.
Citation Text:
Mazor KM, Simon SR, Yood RA, et al. Health plan members' views about disclosure of medical errors. Ann Intern Med. 2004;140(6):409-18.
Copy Citation
Format:
…
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psnet.ahrq.gov/node/34999/psn-pdf
June 22, 2009 - Mentoring staff members as patient safety leaders: the
Clarian Safe Passage Program.
June 22, 2009
Rapala K. Mentoring staff members as patient safety leaders: the Clarian Safe Passage Program. Crit Care
Nurs Clin North Am. 2005;17(2):121-126, ix.
https://psnet.ahrq.gov/issue/mentoring-staff-members-patient-safety…
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery
1
Source and Credits
This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Andrew P.J. …
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psnet.ahrq.gov/node/40675/psn-pdf
November 28, 2016 - Patients' and family members' views on how clinicians
enact and how they should enact incident disclosure: the
"100 patient stories" qualitative study.
November 28, 2016
Iedema R, Allen S, Britton K, et al. Patients' and family members' views on how clinicians enact and how
they should enact incident disclosure: t…
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - When thoughtfully organized and executed, teamwork allows each member of the team to practice "at the … top of their license" so that each team member does work he or she is uniquely suited to perform. … Poon has declared that neither he, nor any immediate member of his family, has a financial arrangement
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psnet.ahrq.gov/node/49448/psn-pdf
June 01, 2004 - In the past, the most junior
member of the OR team was stat paged to fill out a new one, and usually … this team member knew next to
nothing about the case.
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psnet.ahrq.gov/node/49507/psn-pdf
April 01, 2006 - Any member of the crew is empowered to wave off a landing—judgments of safety trump
formal rank. … Bosk has declared that neither he, nor any immediate member of his family, has a
financial arrangement
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psnet.ahrq.gov/node/33566/psn-pdf
September 15, 2024 - Teamwork training
attempts to minimize the potential for error by training each team member to respond
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psnet.ahrq.gov/issue/work-related-factors-cognitive-skills-unsafe-behavior-and-safety-incident-involvement-among
October 27, 2021 - Study
Work-related factors, cognitive skills, unsafe behavior and safety incident involvement among emergency medical services crew members: relationships and indirect effects.
Citation Text:
Sedlár M. Work-related factors, cognitive skills, unsafe behavior and safety incident involvemen…
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psnet.ahrq.gov/issue/what-are-experiences-team-members-involved-root-cause-analysis-qualitative-study
August 16, 2023 - Study
What are the experiences of team members involved in root cause analysis? A qualitative study.
Citation Text:
Willis R, Jones T, Hoiles J, et al. What are the experiences of team members involved in root cause analysis? A qualitative study. BMC Health Serv Res. 2023;23(1):1152. doi…