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psnet.ahrq.gov/node/50795/psn-pdf
January 15, 2020 - Diagnostic error in the emergency department: learning
from national patient safety incident report … Diagnostic error in the emergency department: learning
from national patient safety incident report … https://psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety- … https://psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety-incident-report … https://psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety-incident-report
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psnet.ahrq.gov/sites/default/files/2020-04/spotlight-slides-wright-schiff.pdf
January 01, 2020 - The
discharging nurse reviewed the full medication
list (13 medications) with the patient and his … On re-reviewing the
medications, the wife explained the patient had
been taking both prescriptions … .
6
Case: Lost Start Date (4)
The patient safety committee at the hospital
performed a full review … safety committee learned
that transmission of start and stop date fields in
electronic prescriptions … entry (CPOE) showed it can reduce the rate
of medication errors
• Overall, CPOE has been a positive safety
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psnet.ahrq.gov/node/60028/psn-pdf
March 11, 2020 - medical/surgical or telemetry units throughout seven hospitals were surveyed
about perceptions on safety … culture, patient advocacy, patient experience, and fall and pressure ulcer rates. … Survey results indicated a positive correlation between safety culture and advocacy; however, this
relationship … was moderated by nursing experience, with newer nurses being more positive about safety
culture and … https://psnet.ahrq.gov/issue/creating-safety-culture-nursing-units-human-performance-and-organizational-system-factors
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psnet.ahrq.gov/issue/screening-medication-errors-using-outlier-detection-system
December 18, 2019 - October 10, 2018
Computerized prescriber order entry–related patient safety reports: … October 31, 2014
View More
Related Resources
Assessing the safety … August 7, 2019
Accurate measurement in California's safety-net health systems has gaps … Perspective
The Role of Bar Coding and Smart Pumps in Safety
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psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
June 15, 2024 - Challenges and Threats to Patient Safety Consider a scenario where a patient – Mr. … There is very little research about the correlation of patient-family engagement and patient safety … Strategies to Improve Patient Safety To address these risks, it is vital to create safety nets within … Effective communication between healthcare providers and patients is vital for patient safety and quality … Medication Safety Medication reconciliation has been part of the National Patient Safety Goals since
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psnet.ahrq.gov/node/37438/psn-pdf
June 16, 2010 - Identification of inpatient DNR status: a safety hazard
begging for standardization. … Identification of inpatient DNR status: A safety hazard begging for
standardization. … of nurse leaders at academic medical centers found great variation in the method used to
document patients … This lack of standardization has
been recognized as a patient safety problem, and resources exist to … https://psnet.ahrq.gov/issue/use-color-coded-patient-wristbands-creates-unnecessary-risk
https://psnet.ahrq.gov
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psnet.ahrq.gov/web-mm/dont-push
March 02, 2011 - The patient received IV magnesium sulfate immediately. … Efficacy and safety of IM ziprasidone vs. … February 7, 2024
Impact of team performance on the surgical safety checklist on patient … safety and quality of care: a panel study. … December 21, 2014
Patient safety, satisfaction, and quality of hospital care: cross sectional
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psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
April 26, 2023 - Our role is to analyze data related to patient safety, especially monitoring of general care patients … Our specialty was applying aviation safety concepts to patient safety. … A nurse in general care managing five patients may be busy with one patient when another patient down … state (e.g., via oxygen saturation, pulse rate, and other indicators) and is well-tolerated by patients … National Patient Safety Agency.
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psnet.ahrq.gov/node/866854/psn-pdf
January 01, 2025 - Charting diagnostic safety: exploring patient-provider
discordance in medical record documentation. … Charting diagnostic safety: exploring patient-provider
discordance in medical record documentation. … https://psnet.ahrq.gov/issue/charting-diagnostic-safety-exploring-patient-provider-discordance-medical … https://psnet.ahrq.gov/issue/charting-diagnostic-safety-exploring-patient-provider-discordance-medical-record … https://psnet.ahrq.gov/issue/patient-feedback-reporting-tool-opennotes-implications-patient-clinician-safety-and-quality
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psnet.ahrq.gov/issue/diagnostic-error-medicine-analysis-583-physician-reported-errors
June 24, 2009 - An invited commentary [see link below] by a leader in the patient safety field, Dr. … Resources From the Same Author(s)
Organizational and cultural changes for providing safe patient … Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient … Hospital-based transfusion error tracking from 2005 to 2010: identifying the key errors threatening patient … transfusion safety.
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psnet.ahrq.gov/issue/evaluation-harm-associated-high-dose-range-clinical-decision-support-overrides-intensive-care
August 17, 2018 - Although clinical decision support is intended to improve safety, decision support alerts often result … December 21, 2017
Computerized prescriber order entry–related patient safety reports: … February 14, 2024
Patient Safety Innovations
Remote Response … May 24, 2023
Allergic adverse drug events after alert overrides in hospitalized patients … April 13, 2022
Hospitals look to computers to predict patient emergencies before they
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psnet.ahrq.gov/node/44135/psn-pdf
November 06, 2015 - freedom-speak-review-whistleblowing-nhs
Staff willingness to raise awareness of problems that could affect patient … care is an important indicator of
safety culture. … explores National Health Service (NHS) staff perceptions regarding raising
concerns about health care safety … measures for NHS
organizations to use to help ensure that staff are comfortable raising awareness of patient … safety concerns.
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psnet.ahrq.gov/node/44176/psn-pdf
August 21, 2015 - Patient and carer identified factors which contribute to
safety incidents in primary care: a qualitative … -
care
The patient safety field's understanding of safety issues in ambulatory care continues to evolve … Some of these themes were also found in a prior study of primary care patients in the United Kingdom. … https://psnet.ahrq.gov/issue/trust-temporality-and-systems-how-do-patients-understand-patient-safety-primary-care … https://psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
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psnet.ahrq.gov/issue/effects-patient-environment-and-medication-related-factors-high-alert-medication-incidents
January 22, 2016 - Study
Effects of patient-, environment- and medication-related factors on high-alert … Such medication incidents arose more often in patients who were transferred from one hospital ward to … June 16, 2019
Multicentre study to develop a medication safety package for decreasing … January 7, 2015
Intravenous infusion safety technology: return on investment. … Safety Initiative.
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psnet.ahrq.gov/node/73066/psn-pdf
March 24, 2021 - Patient Safety. 2021;3(1):10-22.
doi:10.33940/data/2021.3.1. … , barriers to
implementation and threats to safety persist. … Based on events reported to the Pennsylvania Patient Safety
Reporting System, the authors characterized … medication-reconciliation
https://psnet.ahrq.gov/issue/problem-medication-reconciliation
https://psnet.ahrq.gov/issue/patient-safety-authority … https://psnet.ahrq.gov/issue/patient-safety-authority
https://psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
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psnet.ahrq.gov/node/49549/psn-pdf
December 06, 2007 - According
to the VA National Center for Patient Safety (NCPS), elopement is defined as: "A patient that … "(
1) Wandering can also lead to significant safety risks when the patient has decreased capacity.(2 … an
elopement tool kit created by the VA Center for Patient Safety.(9) A "yes" to any of the following … Analyzing missing patient events at the VA. TIPS (Topics in Patient Safety). … National Center for Patient Safety. VHA NCPS escape and elopement management.
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psnet.ahrq.gov/issue/prevalence-potentially-inappropriate-prescribing-older-people-primary-care-and-its
September 28, 2016 - A recent PSNet perspective discussed community pharmacists' role in promoting medication safety. … Citation
Related Resources From the Same Author(s)
PIPc study: development of indicators … September 5, 2018
Medication safety incidents associated with the remote delivery of … Changes to primary care delivery during the COVID-19 pandemic and perceived impact on medication safety … May 10, 2023
Annual Perspective
Improving Diagnostic Safety
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psnet.ahrq.gov/issue/relationships-among-psychological-safety-principles-high-reliability-and-safety-reporting
September 16, 2015 - Patient safety event reporting is a key indicator of safety culture . … high-reliability organization were positively associated with patient safety event reporting behaviors … April 16, 2010
To err is human: patient misinterpretations of prescription drug label … November 16, 2022
Predictors and outcomes of patient safety culture: a cross-sectional … an analysis of the 2016 Hospital Survey on Patient Safety Culture.
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psnet.ahrq.gov/node/764405/psn-pdf
March 02, 2022 - Evaluation of communication and safety behaviors during
hospital-wide code response simulation. … response-simulation
Effective team communication is a cornerstone to ensuring safe patient care, particularly … baseline communication behaviors can guide future
interventions to promote and improve quality and patient … safety. … psnet.ahrq.gov/primer/communication-between-clinicians
https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
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psnet.ahrq.gov/issue/patient-safety-primary-care-conceptual-meanings-health-care-team-and-patients
September 28, 2022 - Study
Patient safety in primary care: conceptual meanings to the health care team … and patients. … Patient safety in primary care: conceptual meanings to the health care team and patients. … and staff conceptualize patient safety in primary care . … Patient safety in primary care: conceptual meanings to the health care team and patients.