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psnet.ahrq.gov/node/34723/psn-pdf
April 07, 2011 - cases profiled in
the media and the changes these cases prompted in the medical system, including a number
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psnet.ahrq.gov/node/34890/psn-pdf
February 17, 2011 - The provider involved then received an alert and was given a number of appropriate options.
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psnet.ahrq.gov/node/35207/psn-pdf
December 19, 2009 - This study followed more than 2600 discharged patients from two hospitalist services to capture the
number
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psnet.ahrq.gov/node/43039/psn-pdf
August 24, 2016 - Borrowing from the field of cognitive psychology, a number of
errors stemming from clinicians’ use of
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psnet.ahrq.gov/node/44423/psn-pdf
January 22, 2016 - Furthermore, there was no evidence
of a "July Effect," as the number of morbidity and mortality cases
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psnet.ahrq.gov/node/47054/psn-pdf
July 19, 2018 - Sciences, Engineering, and Medicine called for achieving zero
preventable trauma deaths, but the actual number
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psnet.ahrq.gov/node/34933/psn-pdf
April 06, 2011 - This study observed the delivery of more than 425 IV medication administrations to determine the
number
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psnet.ahrq.gov/node/45974/psn-pdf
May 03, 2017 - The authors
recommend reducing the number of alerts per patient to address alarm fatigue.
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psnet.ahrq.gov/node/39120/psn-pdf
March 04, 2011 - inadequacy of the alerts
themselves was responsible for this failure, with problems including an excessive number
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psnet.ahrq.gov/node/43731/psn-pdf
December 03, 2014 - This study
describes a 150% increase in the number of documented missed injuries that were caught following
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psnet.ahrq.gov/node/46162/psn-pdf
July 26, 2017 - Texas hospitals, investigators found
that hospitals with higher rates of PSIs experienced an increased number
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psnet.ahrq.gov/node/46146/psn-pdf
June 07, 2017 - The number and quality of reports increased following the intervention.
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psnet.ahrq.gov/node/43978/psn-pdf
September 01, 2016 - study describes how inpatient pharmacists modified
alerts on intravenous infusion pumps to reduce the number
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psnet.ahrq.gov/issue/dropping-baton-qualitative-analysis-failures-during-transition-emergency-department-inpatient
September 26, 2012 - September 26, 2016
Safety in numbers: lack of evidence to indicate the number of physicians
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psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
June 01, 2010 - PC: I have the benefit of having analyzed a number of cases that went wrong and so I'm aware of the … PC: I think awareness is number one. … A number of initiatives have been proposed that help us in our decision-making. … We implemented a number of strategies that have significantly improved our feedback. … The number one reason given by physicians for leaving emergency medicine is the shift work.
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psnet.ahrq.gov/node/49438/psn-pdf
March 05, 2004 - the OR schedule and, even with no names identified, this
information can be linked to the OR room number … In addition, no audio is used.
0:48
View
Video
This project was funded under contract number 75Q80119C00004
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - De-identification can be expensive, and it could be done in a number of different ways, which again might … There is no mandate that makes PSOs exist, either a certain number of them or a geographic spread. … You see examples of this all the time—private and governmental organizations that report the number of … Finally, a number of PSOs like CHPSO are associated with professional organizations—in our case, CHA. … With a number of other PSOs wanting to take the same course, vendors providing PSO "backend" services
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psnet.ahrq.gov/node/43340/psn-pdf
July 23, 2014 - Do doctors understand test results?
July 23, 2014
Kremer W.
https://psnet.ahrq.gov/issue/do-doctors-understand-test-results
This magazine article reports how weaknesses in physician understanding of statistics can lead to poorly
informed discussions with patients about risks and treatment options. Using actual num…
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psnet.ahrq.gov/perspective/becoming-patient-safety-organization
July 01, 2011 - Finally, a number of PSOs like CHPSO are associated with professional organizations—in our case, CHA. … With a number of other PSOs wanting to take the same course, vendors providing PSO "backend" services … There is no mandate that makes PSOs exist, either a certain number of them or a geographic spread. … You see examples of this all the time—private and governmental organizations that report the number of … This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research
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psnet.ahrq.gov/node/43276/psn-pdf
June 18, 2014 - Misidentification of alphanumeric symbols.
June 18, 2014
ISMP Medication Safety Alert! Acute care edition. June 5, 2014;19:1-2,4-5.
https://psnet.ahrq.gov/issue/misidentification-alphanumeric-symbols
Written numbers and letters that look alike can contribute to miscommunication in a variety of settings. This
newsl…