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Showing results for "operational".

3541. Communication Error in a Closed ICU | PSNet
      psnet.ahrq.gov/web-mm/communication-error-closed-icu
      July 01, 2016 - Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational

3542. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34691/psn-pdf
      May 18, 2016 - Error in medicine. May 18, 2016 Leape L. Error in medicine. JAMA. 1994;272(23):1851-1857. https://psnet.ahrq.gov/issue/error-medicine Leape discusses how traditional methods of error reduction in medicine have focused on individual performance rather than on the systems in which individuals operate. With reference…

3543. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74231/psn-pdf
      January 12, 2022 - Quality and safety in hospital pediatrics during COVID-19: a national qualitative study. January 12, 2022 De Angulo NR, Penwill N, Pathak PR, et al. Quality and safety in hospital pediatrics during COVID-19: a national qualitative study. Hosp Pediatr. 2022;12(1):e2021006115. doi:10.1542/hpeds.2021-006115. https://…

3544. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46278/psn-pdf
      July 19, 2017 - The opioid epidemic: what can surgeons do about it? July 19, 2017 Saluja S, Selzer D, Meara JG, et al. Bull Am Coll Surg. 2017;102(7):13-18. https://psnet.ahrq.gov/issue/opioid-epidemic-what-can-surgeons-do-about-it Surgeons often prescribe opioids for patients after procedures, so they are in a key position to ass…

3545. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40182/psn-pdf
      September 25, 2011 - Using a data-matrix–coded sponge counting system across a surgical practice: impact after 18 months. September 25, 2011 Cima RR, Kollengode A, Clark J, et al. Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 months. Jt Comm J Qual Patient Saf. 2011;37(2):51-58. https://p…

3546. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37255/psn-pdf
      December 19, 2011 - Communicating in the "gray zone": perceptions about emergency physician-hospitalist handoffs and patient safety. December 19, 2011 Apker J, Mallak LA, Gibson SC. Communicating in the "gray zone": perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007;14(10):884-94. htt…

3547. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39550/psn-pdf
      July 05, 2013 - A novel method for reproducibly measuring the effects of interventions to improve emotional climate, indices of team skills and communication, and threat to patient outcome in a high-volume thoracic surgery center. July 5, 2013 Nurok M, Lipsitz S, Satwicz P, et al. A novel method for reproducibly measuring the eff…

3548. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41541/psn-pdf
      September 26, 2012 - Failures in communication and information transfer across the surgical care pathway: interview study. September 26, 2012 Nagpal K, Arora S, Vats A, et al. Failures in communication and information transfer across the surgical care pathway: interview study. BMJ Qual Saf. 2012;21(10):843-9. https://psnet.ahrq.gov/is…

3549. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41715/psn-pdf
      October 03, 2017 - Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care. October 3, 2017 Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368. https://psnet.ahrq.gov/issue/unaccountable-what-hospitals-wont-tell-you-and-how-transparency-can- revolutionize-health-care This boo…

3550. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/855090/psn-pdf
      January 01, 2024 - Supporting nurses in acute and emergency care settings to speak up. November 8, 2023 Clarke-Romain B. Supporting nurses in acute and emergency care settings to speak up. Emerg Nurse. 2024;32(3):16-21. doi:10.7748/en.2023.e2162. https://psnet.ahrq.gov/issue/supporting-nurses-acute-and-emergency-care-settings-speak …

3551. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44055/psn-pdf
      April 15, 2015 - Health Care Simulation to Advance Safety: Responding to Ebola and Other Threats. April 15, 2015 Rockville, MD: Agency for Healthcare Research and Quality; February 2015. AHRQ Publication No. 15- 0021. https://psnet.ahrq.gov/issue/health-care-simulation-advance-safety-responding-ebola-and-other-threats Simulation …

3552. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73429/psn-pdf
      June 23, 2021 - Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. June 23, 2021 Farnborough, UK: Healthcare Safety Investigation Branch; June 2021. https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings Wrong site/wrong patent surgery is a persisten…

3553. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43047/psn-pdf
      August 02, 2015 - Hospital readmission after noncardiac surgery: the role of major complications. August 2, 2015 Glance LG, Kellermann AL, Osler T, et al. Hospital readmission after noncardiac surgery: the role of major complications. JAMA Surg. 2014;149(5):439-45. https://psnet.ahrq.gov/issue/hospital-readmission-after-noncardiac-…

3554. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43284/psn-pdf
      November 28, 2016 - Parental involvement in the preoperative surgical safety checklist is welcomed by both parents and staff. November 28, 2016 Corbally MT, Tierney E. Parental involvement in the preoperative surgical safety checklist is welcomed by both parents and staff. Int J Pediatr. 2014;2014:791490. doi:10.1155/2014/791490. htt…

3555. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42579/psn-pdf
      November 18, 2013 - Surgical safety checklist compliance: a job done poorly! November 18, 2013 Sparks EA, Wehbe-Janek H, Johnson RL, et al. Surgical Safety Checklist compliance: a job done poorly!. J Am Coll Surg. 2013;217(5):867-73.e1-3. doi:10.1016/j.jamcollsurg.2013.07.393. https://psnet.ahrq.gov/issue/surgical-safety-checklist-com…

3556. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34800/psn-pdf
      December 23, 2008 - A classification system for incidents and accidents in the health-care system. December 23, 2008 Runciman WB, Helps SC, Sexton EJ, et al. A classification for incidents and accidents in the health-care system. J Qual Clin Pract. 1998;18(3):199-211. https://psnet.ahrq.gov/issue/classification-system-incidents-and-a…

3557. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40270/psn-pdf
      March 09, 2011 - Harvey Cushing's open and thorough documentation of surgical mishaps at the dawn of neurologic surgery. March 9, 2011 Latimer K, Pendleton C, Olivi A, et al. Harvey Cushing's open and thorough documentation of surgical mishaps at the dawn of neurologic surgery. Arch Surg. 2011;146(2):226-32. doi:10.1001/archsurg.2…

3558. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48005/psn-pdf
      May 08, 2019 - Why your doctor's white coat can be a threat to your health. May 8, 2019 Haun N, Hooper-Lane C, Safdar N. Healthcare Personnel Attire and Devices as Fomites: A Systematic Review. Infect Control Hosp Epidemiol. 2016;37(11):1367-1373. https://psnet.ahrq.gov/issue/why-your-doctors-white-coat-can-be-threat-your-health…

3559. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866406/psn-pdf
      July 31, 2024 - Impact of a daily huddle on safety in perioperative services. July 31, 2024 Tuyishime H, Claure RE, Balakrishnan K, et al. Impact of a daily huddle on safety in perioperative services. Jt Comm J Qual Patient Saf. 2024;50(9):678-683. doi:10.1016/j.jcjq.2024.04.012. https://psnet.ahrq.gov/issue/impact-daily-huddle-s…

3560. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45251/psn-pdf
      August 24, 2016 - 5 cataract surgeries, 5 people blinded: what went wrong? August 24, 2016 Kowalczyk L. Boston Globe. August 14, 2016. https://psnet.ahrq.gov/issue/5-cataract-surgeries-5-people-blinded-what-went-wrong Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series o…