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9341. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49700/psn-pdf
      February 01, 2014 - About 12 hours after the procedure, the patient's nurse noted a five-beat run of ventricular tachycardia … The nurse called the responsible physician who responded that "this was expected" (given her underlying … However, given the physician's initial response, the nurse did not notify the physician about these additional

9342. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
      March 01, 2007 - later, when removing another vial of ceftriaxone from the automated dispensing cabinet (Pyxis), the nurse … In the medicine administration area, the nurse found a partially empty vial of cefazolin, a different … The nurse who had given this medication was very upset and spoke with the ED physician on duty about

9343. Woman who died at Alta Bates may be victim of medical error not medication mistake. | PSNet
      psnet.ahrq.gov/issue/woman-who-died-alta-bates-may-be-victim-medical-error-not-medication-mistake
      March 23, 2011 - Audiovisual Woman who died at Alta Bates may be victim of medical error not medication mistake. Citation Text: Woodall A. Oakland Tribune. September 27, 2011. Copy Citation Save Print Share Facebook Twitter Linkedin …

9344. Three die at Vets Home after errors. | PSNet
      psnet.ahrq.gov/issue/three-die-vets-home-after-errors
      December 07, 2005 - Newspaper/Magazine Article Three die at Vets Home after errors. Citation Text: Wolfe W. Star Tribune. Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 14, 2007 Wolf…

9345. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73924/psn-pdf
      October 06, 2021 - Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings. October 6, 2021 Weenink J-W, Wallenburg I, Leistikow I, et al. Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and…

9346. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43822/psn-pdf
      July 01, 2016 - Multicentre study to develop a medication safety package for decreasing inpatient harm from omission of time- critical medications. July 1, 2016 Graudins LV, Ingram C, Smith BT, et al. Multicentre study to develop a medication safety package for decreasing inpatient harm from omission of time-critical medications.…

9347. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866400/psn-pdf
      January 01, 2025 - Medication administration in aged care facilities: a mixed- methods systematic review. July 31, 2024 Garratt S, Dowling A, Manias E. Medication administration in aged care facilities: a mixed?methods systematic review. J Adv Nurs. 2025;81(2):621-640. doi:10.1111/jan.16318. https://psnet.ahrq.gov/issue/medication-a…

9348. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43120/psn-pdf
      September 27, 2016 - The Canadian nurse. 2014;110(2):25-9.

9349. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43493/psn-pdf
      February 18, 2015 - psnet.ahrq.gov/issue/multifaceted-initiative-reduce-alarm-fatigue-cardiac-unit-reduces-alarms-and-increases-nurse

9350. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49864/psn-pdf
      June 01, 2019 - Every work setting in health care, from operating rooms to the office practice and visiting nurse group … Discrepant attitudes about teamwork among critical care nurses and physicians. … Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

9351. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33662/psn-pdf
      January 01, 2008 - I won't tell you that there weren't a few doctors here and there who didn't want a nurse assisting in … Initially people were skeptical, but when you start addressing problems that really bother the doctors and nurses … My experience was that I would get calls from physicians or nurses who say, "This isn't right."

9352. Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
      January 01, 2023 - to her delivery.7,8 19 Contributing Factors (3) • The obstetrics team, anesthesiologists, and nurses … at least one provider from obstetrics, anesthesia, nursing, and the operating room surgical scrub nurse

9353. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74143/psn-pdf
      December 01, 2021 - unequal-treatment-confronting-racial-and-ethnic-disparities-health-care https://psnet.ahrq.gov/issue/better-nurse-staffing-associated-survival-black-patients-and-diminishes-racial-disparities

9354. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853076/psn-pdf
      August 30, 2023 - This article summarizes the range of breakdowns that contributed to a British nurse serial murderer,

9355. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866641/psn-pdf
      September 04, 2024 - curated-library/implementation-patient-safety-projects https://psnet.ahrq.gov/issue/chronic-hospital-nurse-understaffing-meets-covid

9356. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46508/psn-pdf
      November 22, 2017 - Crit Care Nurse. 2017;37(5):12-18. doi:10.4037/ccn2017603.

9357. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865680/psn-pdf
      September 06, 2024 - issue/complexity-science-challenge-complexity-health-care https://psnet.ahrq.gov/issue/chronic-hospital-nurse-understaffing-meets-covid

9358. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37679/psn-pdf
      June 12, 2008 - improving-patient-safety-and-uniformity-care-standardized-regimen-use-oxytocin https://psnet.ahrq.gov/issue/nurse-physician-communication-during-labor-and-birth-implications-patient-safety

9359. The PSNet Collection | PSNet
      psnet.ahrq.gov/psnet-collection?search=%7B%22Topic%22%3A%22COVID-19%22%7D&f%5B0%5D=clinical_area%3A5356
      October 27, 2021 - All Content Search Apply Advanced Search Search Tips Save Subscribe to this search Download citations Selection All results on this page Selection Format RIS Download All Content …

9360. Advancing Diagnostic Excellence for Older Adults: Proceedings of a Workshop in Brief. | PSNet
      psnet.ahrq.gov/issue/advancing-diagnostic-excellence-older-adults-proceedings-workshop-brief
      April 20, 2022 - Book/Report Advancing Diagnostic Excellence for Older Adults: Proceedings of a Workshop in Brief. Citation Text: Advancing Diagnostic Excellence for Older Adults: Proceedings of a Workshop in Brief.  National Academies of Sciences, Engineering, and Medicine. Washington, DC: The…