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Showing results for "operational".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43185/psn-pdf
    May 14, 2014 - Preventing health care–associated harm in children. May 14, 2014 Walsh KE, Bundy DG, Landrigan CP. Preventing health care-associated harm in children. JAMA. 2014;311(17):1731-2. doi:10.1001/jama.2014.2038. https://psnet.ahrq.gov/issue/preventing-health-care-associated-harm-children This commentary describes why de…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843091/psn-pdf
    January 25, 2023 - Anesthesia outside of the OR: cause for patient safety concerns? January 25, 2023 DePeau-Wilson M. MedPage Today. January 13, 2023. https://psnet.ahrq.gov/issue/anesthesia-outside-or-cause-patient-safety-concerns The use of anesthesia in ambulatory settings presents both advantage and risk to patients and clinicia…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42026/psn-pdf
    February 20, 2013 - Speaking up—when doctors navigate medical hierarchy. February 20, 2013 Srivastava R. Speaking up--when doctors navigate medical hierarchy. New Engl J Med. 2013;368(4):302- 305. doi:10.1056/NEJMp1212410. https://psnet.ahrq.gov/issue/speaking-when-doctors-navigate-medical-hierarchy This commentary relates a compelli…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847545/psn-pdf
    April 12, 2023 - Normalization of deviance is contrary to the principles of high reliability. April 12, 2023 Wright I. Normalization of deviance Is contrary to the principles of high reliability. AORN J. 2023;117(4):231-238. doi:10.1002/aorn.13894. https://psnet.ahrq.gov/issue/normalization-deviance-contrary-principles-high-reliab…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43354/psn-pdf
    July 16, 2014 - Weaving a healthcare tapestry of safety and communication. July 16, 2014 Hay J, Collin S, Koruth S. Weaving a healthcare tapestry of safety and communication. Nurs Manage. 2014;45(7):40-6. doi:10.1097/01.NUMA.0000451035.84587.7d. https://psnet.ahrq.gov/issue/weaving-healthcare-tapestry-safety-and-communication Th…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41200/psn-pdf
    January 03, 2017 - Implementing a perioperative handoff tool to improve postprocedural patient transfers. January 3, 2017 Petrovic MA, Martinez EA, Aboumatar HJ. Implementing a perioperative handoff tool to improve postprocedural patient transfers. Jt Comm J Qual Patient Saf. 2012;38(3):135-42. https://psnet.ahrq.gov/issue/implement…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38713/psn-pdf
    June 17, 2009 - Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. June 17, 2009 Henrickson SE, Wadhera RK, Elbardissi AW, et al. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. J Am Coll Surg. 2009;208(6):1115-23. doi:10.1016/j.jamcoll…

  8. Adverse Event | PSNet

    psnet.ahrq.gov/taxonomy/term/3437
    May 23, 2025 - Adverse Event Any injury caused by medical care. Examples: pneumothorax from central venous catheter placement anaphylaxis to penicillin postoperative wound infection hospital-acquired delirium (or "sundowning") in elderly patients Identifying something as an adverse event does not imply "error," "negligence," or po…

  9. In Conversation With… Lawrence Smith, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
    February 01, 2012 - In Conversation With… Lawrence Smith, MD February 1, 2012  Also Read an Essay Citation Text: In Conversation With… Lawrence Smith, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. …

  10. In Conversation with… Edward Tenner, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
    June 01, 2011 - In Conversation with… Edward Tenner, PhD June 1, 2011  Also Read an Essay Citation Text: In Conversation with… Edward Tenner, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Cop…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837959/psn-pdf
    August 31, 2022 - Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy August 31, 2022 Kelly KJ. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertio…

  12. EMS Perils from Hospital Overcrowding | PSNet

    psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
    November 25, 2020 - EMS Perils from Hospital Overcrowding Citation Text: Brown S, Rose JS, Barnes DK. EMS Perils from Hospital Overcrowding. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX E…

  13. Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit. | PSNet

    psnet.ahrq.gov/issue/clinical-characteristics-and-short-term-outcomes-acute-kidney-injury-missed-diagnosis-older
    April 20, 2022 - Study Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit. Citation Text: Li Q, Hu P, Kang H, et al. Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis…

  14. Evaluation of policies limiting opioid exposure on opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large American health system. | PSNet

    psnet.ahrq.gov/issue/evaluation-policies-limiting-opioid-exposure-opioid-prescribing-and-patient-pain-opioid-naive
    May 18, 2022 - Study Evaluation of policies limiting opioid exposure on opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large American health system. Citation Text: Rennert L, Howard KA, Walker KB, et al. Evaluation of policies limiting opioid exposure on o…

  15. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. | PSNet

    psnet.ahrq.gov/issue/diagnostic-errors-intensive-care-unit-systematic-review-autopsy-studies
    March 10, 2021 - Review Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. Citation Text: Winters BD, Custer J, Galvagno SM, et al. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. BMJ Qual Saf. 2012;21(11):894-902. doi:10.1136/bmj…

  16. Effect of increased inpatient attending physician supervision on medical errors, patient safety, and resident education: a randomized clinical trial. | PSNet

    psnet.ahrq.gov/issue/effect-increased-inpatient-attending-physician-supervision-medical-errors-patient-safety-and
    December 07, 2011 - Study Emerging Classic Effect of increased inpatient attending physician supervision on medical errors, patient safety, and resident education: a randomized clinical trial. Citation Text: Finn KM, Metlay JP, Chang Y, et al. Effect of Increased Inpatient Attendin…

  17. The perception of patient safety in an alternate site of care for elective surgery during the first wave of the novel coronavirus pandemic in the United Kingdom: a survey of 158 patients. | PSNet

    psnet.ahrq.gov/issue/perception-patient-safety-alternate-site-care-elective-surgery-during-first-wave-novel
    May 12, 2021 - Study The perception of patient safety in an alternate site of care for elective surgery during the first wave of the novel coronavirus pandemic in the United Kingdom: a survey of 158 patients. Citation Text: Lee G, Clough OT, Walker JA, et al. The perception of patient safety in an alte…

  18. Postoperative adverse events inconsistently improved by the World Health Organization surgical safety checklist: a systematic literature review of 25 studies. | PSNet

    psnet.ahrq.gov/issue/postoperative-adverse-events-inconsistently-improved-world-health-organization-surgical
    March 29, 2023 - Review Classic Postoperative adverse events inconsistently improved by the World Health Organization surgical safety checklist: a systematic literature review of 25 studies. Citation Text: de Jager E, McKenna C, Bartlett L, et al. Postoperative adverse events in…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48106/psn-pdf
    July 24, 2019 - Teamwork Toolkit. July 24, 2019 Durham, NC: Duke Center for Healthcare Safety and Quality; June 2019. https://psnet.ahrq.gov/issue/teamwork-toolkit Improving teamwork and communication is a continued focus in the hospital setting. This toolkit is designed to help organizations create a culture that embeds teamwork…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845654/psn-pdf
    March 08, 2023 - NHS staff cried in safety interviews, says watchdog. March 8, 2023 Reed J. BBC. February 27, 2023. https://psnet.ahrq.gov/issue/nhs-staff-cried-safety-interviews-says-watchdog Stressful and caustic work environments are known to compromise health care safety and teamwork. This news story discusses an ongoing inves…
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