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Showing results for "operational".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43753/psn-pdf
    December 10, 2014 - Improving the quality and safety of patient care in cardiac anesthesia. December 10, 2014 Merry A, Weller J, Mitchell SJ. Improving the quality and safety of patient care in cardiac anesthesia. J Cardiothorac Vasc Anesth. 2014;28(5):1341-51. doi:10.1053/j.jvca.2014.02.018. https://psnet.ahrq.gov/issue/improving-qu…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44260/psn-pdf
    November 06, 2015 - Innovative teaching in situational awareness. November 6, 2015 Gregory A, Hogg G, Ker J. Innovative teaching in situational awareness. Clin Teach. 2015;12(5):331-5. doi:10.1111/tct.12310. https://psnet.ahrq.gov/issue/innovative-teaching-situational-awareness Nontechnical skills contribute to successful teamwork an…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45756/psn-pdf
    December 21, 2016 - Accidental IV infusion of heparinized irrigation in the OR. December 21, 2016 ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3. https://psnet.ahrq.gov/issue/accidental-iv-infusion-heparinized-irrigation-or Accidental administration of irrigation solutions are a wrong-route error that can re…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866257/psn-pdf
    July 25, 2024 - Enhancing Surgical Team Communication: SOPS and TeamSTEPPS in Action. July 10, 2024 Agency for Healthcare Research and Quality. July 25, 2024. https://psnet.ahrq.gov/issue/enhancing-surgical-team-communication-sops-and-teamstepps-action Teamwork in the surgical suite is core to safe care but can be challenging to …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43661/psn-pdf
    November 05, 2014 - The human factor. November 5, 2014 Langewiesche W. https://psnet.ahrq.gov/issue/human-factor This magazine article provides a breakdown of the failures that contributed to an airplane crash, including how increasing automation in piloting airplanes can diminish human performance, the reluctance to speak up due to…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40490/psn-pdf
    June 01, 2011 - Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. June 1, 2011 Joy BF, Elliott E, Hardy C, et al. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit*. Pediatric Critical Care Medicine. 2010…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45789/psn-pdf
    January 11, 2017 - Concurrent and Overlapping Surgeries: Additional Measures Warranted. January 11, 2017 US Senate Finance Committee. December 6, 2016. https://psnet.ahrq.gov/issue/concurrent-and-overlapping-surgeries-additional-measures-warranted The practice of scheduling concurrent surgeries has raised concerns about increased ri…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34930/psn-pdf
    April 06, 2011 - "Going solid": a model of system dynamics and consequences for patient safety. April 6, 2011 Cook R, Rasmussen J. "Going solid": a model of system dynamics and consequences for patient safety. Qual Saf Health Care. 2005;14(2):130-4. https://psnet.ahrq.gov/issue/going-solid-model-system-dynamics-and-consequences-pa…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855000/psn-pdf
    November 01, 2023 - Perioperative Safety Culture: Principles, Practices, and Pragmatic Approaches. November 1, 2023 McEvoy MD, Abernathy JH, 3rd. Anesthesiol Clin. 2023;41(4):xvii-xix;693-886. https://psnet.ahrq.gov/issue/perioperative-safety-culture-principles-practices-and-pragmatic-approaches Organizational, unit, and team culture…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867451/psn-pdf
    January 21, 2025 - Engineering Safety into Practice through Implementation of the EHR SAFER Guides. January 8, 2025 National Action Alliance for Patient and Workforce Safety. Engineering Safety into Practice through Implementation of the EHR SAFER Guides. January 21, 2025, 12:00 - 1:00 PM (eastern). https://psnet.ahrq.gov/issue/engi…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60696/psn-pdf
    July 15, 2020 - Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries. July 15, 2020 de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 119. https://psnet.ahrq.gov/…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866358/psn-pdf
    July 24, 2024 - To improve health care, focus on fixing systems — not people. July 24, 2024 Mate KS, Clark J, Salvon-Harman J. To improve health care, focus on fixing systems — not people. Harvard Business Review. July 12, 2024; https://psnet.ahrq.gov/issue/improve-health-care-focus-fixing-systems-not-people While a focus on the…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60897/psn-pdf
    January 01, 2022 - Association between surgeon technical skills and patient outcomes. September 9, 2020 Stulberg JJ, Huang R, Kreutzer L, et al. Association Between Surgeon Technical Skills and Patient Outcomes. JAMA Surg. 2022;157(3):219-220. doi:10.1001/jamasurg.2020.3007. https://psnet.ahrq.gov/issue/association-between-surgeon-t…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44221/psn-pdf
    September 27, 2016 - Reducing surgical errors: implementing a three-hinge approach to success. September 27, 2016 Landers R. Reducing surgical errors: implementing a three-hinge approach to success. AORN J. 2015;101(6):657-65. doi:10.1016/j.aorn.2015.04.013. https://psnet.ahrq.gov/issue/reducing-surgical-errors-implementing-three-hing…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42625/psn-pdf
    November 08, 2013 - Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items. November 8, 2013 Judson TJ, Howell MD, Guglielmi C, et al. Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items. Jt Comm J Qual Patient Saf. 2013;39(10):4…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41188/psn-pdf
    March 07, 2012 - Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients. March 7, 2012 Nakayama DK, Lester SS, Rich DR, et al. Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients. J Pediatr Surg. 2012;47(1):112-8. …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865682/psn-pdf
    April 24, 2024 - Global Medical Supply Chain Security. April 24, 2024 Cadwallader AB, ed. AMA J Ethics. 2024;26(4):e275-e359. https://psnet.ahrq.gov/issue/global-medical-supply-chain-security Drug shortages are a known problem that gained patient safety prominence during the COVID-19 pandemic. This special issue covers a rang…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39914/psn-pdf
    October 13, 2010 - Clinical handover of patients arriving by ambulance to the emergency department: a literature review. October 13, 2010 Bost N, Crilly J, Wallis M, et al. Clinical handover of patients arriving by ambulance to the emergency department - a literature review. Int Emerg Nurs. 2010;18(4):210-20. doi:10.1016/j.ienj.2009.…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854252/psn-pdf
    October 04, 2023 - Standardization and visualization of the surgical time-out. October 4, 2023 Levy BE, Wilt WS, Lantz S, et al. Standardization and visualization of the surgical time-out. J Patient Saf. 2023;19(7):453-459. doi:10.1097/pts.0000000000001156. https://psnet.ahrq.gov/issue/standardization-and-visualization-surgical-time-…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46736/psn-pdf
    December 17, 2018 - Back to basics: the Universal Protocol. December 17, 2018 Spruce L. Back to Basics: The Universal Protocol: 1.4 www.aornjournal.org/content/cme. AORN J. 2018;107(1):116-125. doi:10.1002/aorn.12002. https://psnet.ahrq.gov/issue/back-basics-universal-protocol Wrong-site, wrong-procedure, and wrong-patient errors are…
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