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Showing results for "occurred".

  1. Surgical fires: decreasing incidence relies on continued prevention efforts. | PSNet

    psnet.ahrq.gov/issue/surgical-fires-decreasing-incidence-relies-continued-prevention-efforts
    April 03, 2019 - Newspaper/Magazine Article Surgical fires: decreasing incidence relies on continued prevention efforts. Citation Text: Surgical fires: decreasing incidence relies on continued prevention efforts. Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. PA-PSRS Pa Patient Saf Advis. June…

  2. Hearing: Broken Promises: Assessing VA’s Systems for Protecting Veterans from Clinical Harm. | PSNet

    psnet.ahrq.gov/issue/hearing-broken-promises-assessing-vas-systems-protecting-veterans-clinical-harm
    December 23, 2012 - Congressional Testimony Hearing: Broken Promises: Assessing VA’s Systems for Protecting Veterans from Clinical Harm. Citation Text: Hearing: Broken Promises: Assessing VA’s Systems for Protecting Veterans from Clinical Harm. US House of Representatives Committee on Veterans Affairs Subco…

  3. A new method to guard inpatient medication safety by the implementation of RFID. | PSNet

    psnet.ahrq.gov/issue/new-method-guard-inpatient-medication-safety-implementation-rfid
    June 29, 2011 - Study A new method to guard inpatient medication safety by the implementation of RFID. Citation Text: Sun PR, Wang BH, Wu F. A new method to guard inpatient medication safety by the implementation of RFID. J Med Syst. 2008;32(4):327-32. Copy Citation Format: Google Schola…

  4. Why your TeamSTEPPS program may not be working. | PSNet

    psnet.ahrq.gov/issue/why-your-teamstepps-program-may-not-be-working
    February 14, 2024 - Commentary Why your TeamSTEPPS program may not be working. Citation Text: Clapper TC, Ng GM. Why Your TeamSTEPPS™ Program May Not Be Working. Clin Simul Nurs. 2012;9(8). doi:10.1016/j.ecns.2012.03.007. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote …

  5. Errors originating in hospital and health-system outpatient pharmacies. | PSNet

    psnet.ahrq.gov/issue/errors-originating-hospital-and-health-system-outpatient-pharmacies
    December 19, 2016 - Newspaper/Magazine Article Errors originating in hospital and health-system outpatient pharmacies. Citation Text: Errors originating in hospital and health-system outpatient pharmacies. Straka M, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. June 2017;14:55-63. Copy Citation …

  6. Do no unconscious harm. | PSNet

    psnet.ahrq.gov/issue/do-no-unconscious-harm
    October 14, 2020 - Newspaper/Magazine Article Do no unconscious harm. Citation Text: Ortega RP. Do no unconscious harm. Science. 2023;379(6635):870-873. doi:10.1126/science.adh3698. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  7. The safety culture in a children's hospital. | PSNet

    psnet.ahrq.gov/issue/safety-culture-childrens-hospital
    October 06, 2011 - Study The safety culture in a children's hospital. Citation Text: Grant MJC, Donaldson AE, Larsen G. The safety culture in a children's hospital. J Nurs Care Qual. 2006;21(3):223-229. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …

  8. Emergency lights and sirens on ambulances may do more harm than good. | PSNet

    psnet.ahrq.gov/issue/emergency-lights-and-sirens-ambulances-may-do-more-harm-good
    February 15, 2023 - Newspaper/Magazine Article Emergency lights and sirens on ambulances may do more harm than good. Citation Text: Emergency lights and sirens on ambulances may do more harm than good. Renault M. Stat. July 7, 2023. Copy Citation Save Save to your library Pri…

  9. Improving the usability of intravenous medication labels to support safe medication delivery. | PSNet

    psnet.ahrq.gov/issue/improving-usability-intravenous-medication-labels-support-safe-medication-delivery
    September 26, 2016 - Study Improving the usability of intravenous medication labels to support safe medication delivery. Citation Text: Bauer DT, Guerlain S. Improving the usability of intravenous medication labels to support safe medication delivery. International journal of industrial ergonomics. 2011;41…

  10. Ripped apart: medical misdiagnosis and malpractice. | PSNet

    psnet.ahrq.gov/issue/ripped-apart-medical-misdiagnosis-and-malpractice
    August 25, 2021 - Audiovisual Presentation Ripped apart: medical misdiagnosis and malpractice. Citation Text: Ripped apart: medical misdiagnosis and malpractice. Kast S, Gerr M, Black D, et al. “On the Record.” WYPR. August 3, 2021 Copy Citation Save Save to your library …

  11. Losing the moment: understanding interruptions to nurses' work. | PSNet

    psnet.ahrq.gov/issue/losing-moment-understanding-interruptions-nurses-work
    September 19, 2012 - Study Losing the moment: understanding interruptions to nurses' work. Citation Text: Hall LMG, Pedersen C, Fairley L. Losing the moment: understanding interruptions to nurses' work. J Nurs Adm. 2010;40(4):169-176. doi:10.1097/NNA.0b013e3181d41162. Copy Citation Format: DOI …

  12. Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane. | PSNet

    psnet.ahrq.gov/issue/senators-threaten-consequences-after-va-confirms-4-deaths-tied-computer-system-tested-spokane
    September 21, 2022 - Newspaper/Magazine Article Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane. Citation Text: Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane. Donovan-Smith O. Spokesman Review. March 15,…

  13. Prevention of medical accidents caused by defective surgical instruments. | PSNet

    psnet.ahrq.gov/issue/prevention-medical-accidents-caused-defective-surgical-instruments
    July 31, 2019 - Study Prevention of medical accidents caused by defective surgical instruments. Citation Text: Yasuhara H, Fukatsu K, Komatsu T, et al. Prevention of medical accidents caused by defective surgical instruments. Surgery. 2012;151(2):153-61. doi:10.1016/j.surg.2011.06.029. Copy Citation…

  14. Maximize benefits of IV workflow management systems by addressing workarounds and errors. | PSNet

    psnet.ahrq.gov/issue/maximize-benefits-iv-workflow-management-systems-addressing-workarounds-and-errors
    May 31, 2017 - Newspaper/Magazine Article Maximize benefits of IV workflow management systems by addressing workarounds and errors. Citation Text: Maximize benefits of IV workflow management systems by addressing workarounds and errors. ISMP Medication Safety Alert! Acute care edition. September 7, 20…

  15. Funding Announcement for Projects Targeting the Reduction of Healthcare-Associated Infections. | PSNet

    psnet.ahrq.gov/issue/funding-announcement-projects-targeting-reduction-healthcare-associated-infections
    August 01, 2012 - Grant Announcement Funding Announcement for Projects Targeting the Reduction of Healthcare-Associated Infections. Citation Text: Funding Announcement for Projects Targeting the Reduction of Healthcare-Associated Infections. Rockville, MD: Agency for Healthcare Research and Quality; July …

  16. Safety cultural preconditions for organizational learning in high-risk organizations. | PSNet

    psnet.ahrq.gov/issue/safety-cultural-preconditions-organizational-learning-high-risk-organizations
    June 17, 2009 - Commentary Safety cultural preconditions for organizational learning in high-risk organizations. Citation Text: Naevestad T-O. Safety Cultural Preconditions for Organizational Learning in High-Risk Organizations. J Contingencies Crisis Manage. 2008;16(3):154-163. doi:10.1111/j.1468-5973.…

  17. Creating a culture of safety by coaching clinicians to competence. | PSNet

    psnet.ahrq.gov/issue/creating-culture-safety-coaching-clinicians-competence
    January 10, 2024 - Commentary Creating a culture of safety by coaching clinicians to competence. Citation Text: Duff B. Creating a culture of safety by coaching clinicians to competence. Nurse Educ Today. 2013;33(10):1108-11. doi:10.1016/j.nedt.2012.05.025. Copy Citation Format: DOI Googl…

  18. More hospitals move to confront medical errors head on. | PSNet

    psnet.ahrq.gov/issue/more-hospitals-move-confront-medical-errors-head
    June 21, 2023 - Audiovisual More hospitals move to confront medical errors head on. Citation Text: More hospitals move to confront medical errors head on. Gorenstein D. Tradeoffs. November 16, 2023. Copy Citation Save Save to your library Print Download PDF Shar…

  19. Spotlight Case September 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
    September 01, 2003 - Spotlight Case September 2003 Spotlight Case September 2003 Infant Paralyzed for Intubation Before Airway Materials Ready Source and Credits This presentation is based on the Sept. 2003 AHRQ WebM&M Spotlight Case in Pediatrics See the full article at http://webmm.ahrq.gov CME credit is available through the …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33755/psn-pdf
    September 01, 2013 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety September 1, 2013 Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/what-weve-learned-ab…
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