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psnet.ahrq.gov/issue/effect-clinician-feedback-interventions-opioid-prescribing
November 17, 2021 - Opioid overdose and misuse continues to be a major public health concern with numerous policy - and organization
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psnet.ahrq.gov/node/867427/psn-pdf
December 18, 2024 - The World
Health Organization reports falls as the second leading cause of unintentional injury deaths … World Health Organization. Falls. www.who.int.
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Jaenic Lee, MD Josh Fernel…
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psnet.ahrq.gov/web-mm/double-dose-transfer
November 01, 2012 - absence of an integrated EMR, automated medication dispensing (AMD) devices can be used throughout the organization … AMD systems can display the time a medication was last removed, regardless of where in the organization
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psnet.ahrq.gov/issue/nursing2006-patient-safety-survey-report
May 17, 2006 - Journal Article
Study
Published May 17, 2006
Nursing2006 Patient-safety survey report.
Manno M, Hogan P, Heberlein V, et al. Nursing . 2006; 36(5) :54-64 .
Topics
Approach to Improving Safety
…
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psnet.ahrq.gov/issue/international-forum-quality-safety-healthcare-sydney
April 30, 2020 - Meeting/Conference
Asia Meeting/Conference
Published April 30, 2020
International Forum on Quality & Safety in Healthcare: Sydney.
British Medical Journal, Institute for Healthcare Improvement. June 7-9, 2021. International Convention Centre (ICC) Sydney, Sydney, Australia.
Topics
Approach to Improving Safety
Co…
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psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
November 30, 2023 - requires shared reasoning is important because of the increasing division of labor in most healthcare organizations … To optimize patient safety and patient-centered care, health care organizations must have mechanisms
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psnet.ahrq.gov/periodic-issue/periodic-issue-346
May 16, 2022 - This article summarizes an Anesthesia Patient Safety Foundation statement directing organizations and … In her professional role, she provides strategic direction for the research mission of the organization
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psnet.ahrq.gov/periodic-issue/periodic-issue-406
August 30, 2023 - This survey of 118 nursing homes in Switzerland found that organizations employ a variety of electronic … Whistleblowers can identify the presence of systemic failures, but the organization is responsible for
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psnet.ahrq.gov/periodic-issue/periodic-issue-392
April 26, 2023 - proactive risk assessment, ideally prior to the merger, can identify strengths and weaknesses of the organizations … of information (e.g., deficiencies in content), and (2) causes related to the health professional or organization
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psnet.ahrq.gov/issue/safety-relevant-mode-confusions-modelling-and-reducing-them
April 28, 2021 - Analysis of incident reports from a patient safety organization. … November 15, 2023
Fostering a just culture in healthcare organizations: experiences in
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psnet.ahrq.gov/periodic-issue/periodic-issue-456
September 25, 2024 - changing work environment, such as external disruptions or challenging working conditions; (2) the organization … Reliability Solutions at Press Ganey, with over 20 years of experience in safety science and high reliability organizations
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psnet.ahrq.gov/periodic-issue/periodic-issue-427
February 28, 2024 - Geneva; World Health Organization; December 2023. ISBN: 9789240081987. … This publication spotlights actions that various types of organizations and leaders can take to develop
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psnet.ahrq.gov/periodic-issue/periodic-issue-433
March 27, 2024 - Barbara Pelletreau is a former senior vice president of patient safety for a large healthcare organization … We spoke to them about the risks of cybersecurity to patient safety and how organizations can prepare
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psnet.ahrq.gov/node/33614/psn-pdf
June 01, 2005 - know little about other infection control programs introduced at the time, changes to
ICU staffing or organization … Safety culture assessment: a tool for improving patient safety in healthcare
organizations.
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psnet.ahrq.gov/node/860015/psn-pdf
September 01, 2024 - psnet.ahrq.gov//#1
licensing or public health authorities; (2) voluntary reporting to Patient Safety Organizations … In these cases, there is still internal organizational reporting where the organization (1) discloses
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psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - conveyed back
to the original diagnostician, as patients weave their way through different health care organizations … or
different silos of the same organization.
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psnet.ahrq.gov/web-mm/infused-not-ingested
February 01, 2017 - That is, when an error occurs, can an employee safely come forward so that the organization can learn … individual nurses are, and should be, held accountable for their actions leading to errors, health care organizations
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psnet.ahrq.gov/node/49678/psn-pdf
March 01, 2013 - Still, I and the organizations listed above believe it is safest and should be standard of practice to … World Health Organization standard growth
charts indicate that the 98th percentile cut-off for a 17-
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psnet.ahrq.gov/node/49747/psn-pdf
December 01, 2015 - silencing alarms on patient
monitoring devices.(4) Moreover, several federal agencies and national organizations … Committees
charged with addressing alarm management should be formed and include all levels of the organization