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9601. Medication Mix-Up: From Bad to Worse | PSNet
      psnet.ahrq.gov/web-mm/medication-mix-bad-worse
      March 01, 2018 - While the medication mix-up was not identified by the dispensing pharmacist, the nurse responsible for … While comparing the medication order to the delivered medication, the nurse discovered that the incorrect … administration.( 3 ) If the order had been entered correctly, a BCMA alert likely would have signaled a nurse … packaged dose will confirm the order as correct when it is not—perhaps even falsely reassuring a nurse

9602. Perils in Diagnosing a Stroke | PSNet
      psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
      August 15, 2017 - After the thrombolytic was administered, the patient's nurse noticed multiple patches on the patient's … The nurse asked a pharmacy technician to perform medication reconciliation, which revealed that the patient's … The nurse alerted the physician, who realized that the opioid overdose probably explained the patient's … In thinking about this case, the communication among the nurse, ED physician, and the neurologist as

9603. Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. | PSNet
      psnet.ahrq.gov/issue/sentinel-event-alert-67-preserving-patient-safety-after-cyberattack
      March 13, 2024 - Sentinel Event Alerts Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. Citation Text: Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. Jt Comm J Qual Patient Saf. 2023;49(12):724-729. doi:10.1016/j.jcjq.2023.07.006. Copy Citation Format…

9604. Clinical Handover: Critical Communications. | PSNet
      psnet.ahrq.gov/issue/clinical-handover-critical-communications
      February 18, 2015 - Special or Theme Issue Clinical Handover: Critical Communications. Citation Text: Clinical Handover: Critical Communications. Med J Aust. 2009;190(s11):s108-s157. Copy Citation Save Save to your library Print Download PDF Share Facebook …

9605. Toolkit for Improving Surgical Care and Recovery. | PSNet
      psnet.ahrq.gov/issue/toolkit-improving-surgical-care-and-recovery
      September 18, 2024 - Toolkit Toolkit for Improving Surgical Care and Recovery. Citation Text: Agency for Healthcare Research and Quality. Toolkit for Improving Surgical Care and Recovery. June 2023. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…

9606. Technology has transformed the VA. | PSNet
      psnet.ahrq.gov/issue/technology-has-transformed-va
      October 07, 2008 - Newspaper/Magazine Article Technology has transformed the VA. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 24, 2006 View more articles from the same authors. This arti…

9607. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38411/psn-pdf
      December 16, 2014 - In this study, a discharge advocate (a trained nurse) met with patients prior to discharge and created

9608. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46587/psn-pdf
      January 23, 2019 - psnet.ahrq.gov/issue/barcode-medication-administration-work-arounds-systematic-review-and-implications-nurse

9609. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39176/psn-pdf
      December 16, 2009 - cardiac arrests after implementing a rapid response team (RRT) consisting of a critical care physician, nurse

9610. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46986/psn-pdf
      June 27, 2018 - frequency-intravenous-medication-administration-errors-related-smart-infusion-pumps https://psnet.ahrq.gov/issue/impact-traditional-and-smart-pump-infusion-technology-nurse-medication-administration

9611. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/844790/psn-pdf
      January 01, 2020 - A previous WebM&M commentary discussed an incident involving a nurse who bypassed the double-check policy

9612. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40393/psn-pdf
      December 21, 2014 - challenging in inpatient medicine wards, due to numerous barriers including variability in physician and nurse

9613. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44635/psn-pdf
      June 21, 2016 - There were no differences in event rates among resident physicians, nurse anesthetists, and staff anesthesiologists

9614. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2021-11/spotlight_integration_and_coordination_of_disesase_treatment_and_palliative_care_final.pdf
      January 01, 2021 - such as: – Social work referral for transportation or caregiver resources – Additional visits with a registered … nurse or an advanced practice provider to improve understanding of care and symptom management • … A referral to home based palliative care was also completed and the physician-nurse-social worker-chaplain … Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

9615. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43599/psn-pdf
      August 04, 2015 - Intervention have successfully prevented readmissions by using a dedicated transition provider (usually a nurse

9616. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
      May 01, 2009 - The daughter asked the nurse what happened, and reiterated that her mother had never been confused before

9617. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50931/psn-pdf
      February 26, 2020 - multidisciplinary conference might have prompted the patient’s intensivist(s), radiologist(s), surgeon, or nurses

9618. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49793/psn-pdf
      May 01, 2017 - appropriate hospital and/or clinic personnel, identify locations with elevated rates, and work with nurses

9619. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50697/psn-pdf
      November 27, 2019 - Policies that enhance these safety checks could prevent adverse events by engaging nurses, physicians

9620. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33747/psn-pdf
      March 01, 2013 - which enrolled well over 50,000 participants including student and practicing physicians, dentists, nurses