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Showing results for "operational".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866809/psn-pdf
    September 25, 2024 - Stop the line: interventions to prevent retained surgical items. September 25, 2024 Angelilli S. Stop the line: interventions to prevent retained surgical items. AORN J. 2024;120(2):71-81. doi:10.1002/aorn.14190. https://psnet.ahrq.gov/issue/stop-line-interventions-prevent-retained-surgical-items Retained surgica…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46222/psn-pdf
    June 21, 2017 - Enhanced time out: an improved communication process. June 21, 2017 Nelson PE. Enhanced Time Out: An Improved Communication Process. AORN J. 2017;105(6):564-570. doi:10.1016/j.aorn.2017.03.014. https://psnet.ahrq.gov/issue/enhanced-time-out-improved-communication-process The Universal Protocol requires hospitals t…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39504/psn-pdf
    May 05, 2010 - Patient whiteboards as a communication tool in the hospital setting: A survey of practices and recommendations. May 5, 2010 Sehgal NL, Green A, Vidyarthi A, et al. Patient whiteboards as a communication tool in the hospital setting: a survey of practices and recommendations. J Hosp Med. 2010;5(4):234-9. doi:10.100…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43625/psn-pdf
    October 29, 2014 - Assessing distractors and teamwork during surgery: developing an event-based method for direct observation. October 29, 2014 Seelandt JC, Tschan F, Keller S, et al. Assessing distractors and teamwork during surgery: developing an event-based method for direct observation. BMJ Qual Saf. 2014;23(11):918-29. doi:10.11…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38044/psn-pdf
    September 10, 2008 - Comparative issues in aviation and surgical crew resource management: (1) are we too solution focused? September 10, 2008 Hunt GJF, Callaghan KSN. COMPARATIVE ISSUES IN AVIATION AND SURGICAL CREW RESOURCE MANAGEMENT: (1) ARE WE TOO SOLUTION FOCUSED? ANZ J Surg. 2008;78(8). doi:10.1111/j.1445- 2197.2008.04619.x. h…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60268/psn-pdf
    April 29, 2020 - Complications of ECMO During Transport April 29, 2020 Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport The Case A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with acute on chro…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867850/psn-pdf
    February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/persp…

  8. Misconnection Leading to Arterial Thrombosis | PSNet

    psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
    January 29, 2021 - Misconnection Leading to Arterial Thrombosis Citation Text: Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar Bib…

  9. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event | PSNet

    psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
    July 01, 2017 - SPOTLIGHT CASE “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event Citation Text: Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45579/psn-pdf
    November 01, 2017 - Factors influencing patient safety during postoperative handover. November 1, 2017 Rose M, Newman SD. AANA J. 2016;84:329-338. https://psnet.ahrq.gov/issue/factors-influencing-patient-safety-during-postoperative-handover Patient handoffs between care teams are vulnerable to error. This scoping review explored the …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845350/psn-pdf
    March 01, 2023 - Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists. March 1, 2023 Kelly FE, Frerk C, Bailey CR, et al. Implementing human factors in anaesthesia: guidance for clinicians, departments and h…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847043/psn-pdf
    April 05, 2023 - An evidence synthesis on perioperative handoffs: a call for balanced sociotechnical solutions. April 5, 2023 Abraham J, Duffy C, Kandasamy M, et al. An evidence synthesis on perioperative handoffs: a call for balanced sociotechnical solutions. Int J Med Inform. 2023;174:105038. doi:10.1016/j.ijmedinf.2023.105038. …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836752/psn-pdf
    March 16, 2022 - The necessary leadership skillsets for the high-reliability organization framework adoption within acute healthcare organizations. March 16, 2022 Logan?Athmer AL. The necessary leadership skillsets for the high?reliability organization framework adoption within acute healthcare organizations. J Healthc Risk Manag.…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74845/psn-pdf
    February 16, 2022 - Care transition of trauma patients: processes with articulation work before and after handoff. February 16, 2022 Wooldridge AR, Carayon P, Hoonakker PLT, et al. Care transition of trauma patients: processes with articulation work before and after handoff. Appl Ergon. 2022;98:103606. doi:10.1016/j.apergo.2021.10360…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37309/psn-pdf
    January 05, 2012 - Adverse drug events in hospitalized cardiac patients. January 5, 2012 Fanikos J, Cina J, Baroletti S, et al. Adverse drug events in hospitalized cardiac patients. Am J Cardiol. 2007;100(9):1465-9. https://psnet.ahrq.gov/issue/adverse-drug-events-hospitalized-cardiac-patients This study noted two adverse drug event…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45867/psn-pdf
    April 12, 2017 - The Economics of Patient Safety: Strengthening a Value- based Approach to Reducing Patient Harm at National Level. April 12, 2017 Slawomirski L, Auraaen A, Klazinga N. Organisation for Economic Co-operation and Development: Paris, France; 2017. https://psnet.ahrq.gov/issue/economics-patient-safety-strengthening-v…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43779/psn-pdf
    May 28, 2015 - Debriefing in the emergency department after clinical events: a practical guide. May 28, 2015 Kessler DO, Cheng A, Mullan PC. Debriefing in the Emergency Department After Clinical Events: A Practical Guide. Ann Emerg Med. 2015;65(6):690-698. doi:10.1016/j.annemergmed.2014.10.019. https://psnet.ahrq.gov/issue/debri…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47066/psn-pdf
    July 11, 2018 - The association between nurse staffing and omissions in nursing care: a systematic review. July 11, 2018 Griffiths P, Recio-Saucedo A, Dall'Ora C, et al. The association between nurse staffing and omissions in nursing care: A systematic review. J Adv Nurs. 2018;74(7):1474-1487. doi:10.1111/jan.13564. https://psnet…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44916/psn-pdf
    June 01, 2016 - Implementing situation-background-assessment- recommendation in an anaesthetic clinic and subsequent information retention among receivers: a prospective interventional study of postoperative handovers. June 1, 2016 Randmaa M, Swenne CL, Mårtensson G, et al. Implementing situation-background-assessment- recommend…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34881/psn-pdf
    January 05, 2017 - Communicating critical test results: safe practice recommendations. January 5, 2017 Hanna D, Griswold P, Leape L, et al. Communicating critical test results: safe practice recommendations. Jt Comm J Qual Patient Saf. 2005;31(2):68-80. https://psnet.ahrq.gov/issue/communicating-critical-test-results-safe-practice-r…
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