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psnet.ahrq.gov/node/47667/psn-pdf
February 27, 2019 - https://psnet.ahrq.gov/issue/it-time-define-antimicrobial-never-events
Never events are devastating to patients … and indicate serious underlying organizational safety problems. … prevalence-inappropriate-antibiotic-prescriptions-among-us-ambulatory-care-visits-2010-2011
https://psnet.ahrq.gov/issue/vital-signs-improving-antibiotic-use-among-hospitalized-patients
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psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
April 24, 2024 - A recent retrospective cohort study evaluated the safety of 10% calcium chloride administration via peripheral … patients) were associated with low-grade infusion-related adverse events (IRAE). … The median time to IRAE was 71 hours and no patient received plastic surgery consultation or medications … and Patient Safety Target
As this case highlights, selecting the safest feasible mode of infusion … When a patient complains of pain or discomfort around the IV site, the infusion should be stopped, and
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psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
September 01, 2004 - desired, retracts it, and then optionally enters a new but closely related order, and they are useful indicators … Discourses about patient safety tend to involve a good deal of talk about systems thinking, but actually … Leapfrog initiatives to drive great leaps in patient safety.
2. Ranji S, Wachter RM, Hartman EE. … Patient Safety Primer: Computerized Provider Order Entry. AHRQ Patient Safety Network. … Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. 2nd ed.
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psnet.ahrq.gov/issue/patient-safety-orthopedic-surgery-prioritizing-key-areas-iatrogenic-harm-through-analysis
December 18, 2013 - Study
Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic … Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of … System came from trauma and orthopedic surgery patients. … February 3, 2021
Patient safety: it takes a team. … June 10, 2013
Use of the WHO surgical safety checklist in trauma and orthopaedic patients
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psnet.ahrq.gov/issue/comparing-nicu-teamwork-and-safety-climate-across-two-commonly-used-survey-instruments
November 20, 2019 - survey tools—the Safety Attitudes Questionnaire and the Hospital Survey on Patient Safety Culture … consensus-driven research agenda for better understanding and supporting the emotional impact of harmful events on patients … April 12, 2011
Toward learning from patient safety reporting systems. … January 12, 2011
One intensive care nursery's experience with enhancing patient safety … September 27, 2010
Measuring perinatal patient safety: review of current methods.
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psnet.ahrq.gov/issue/international-perspective-definitions-and-terminology-used-describe-serious-reportable
August 04, 2021 - Defining and measuring patient safety is an ongoing challenge . … This systematic review explored international approaches to defining serious reportable patient safety … December 1, 2021
What do patients and their carers do to support the safety of cancer … patient and workforce safety. … August 26, 2020
Scoping review of patients' attitudes about their role and behaviours
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psnet.ahrq.gov/node/74754/psn-pdf
February 09, 2022 - Adverse events during intrahospital transport of critically
ill patients: a systematic review and meta-analysis … Adverse events during intrahospital transport of critically ill
patients: A systematic review and meta-analysis … https://psnet.ahrq.gov/issue/adverse-events-during-intrahospital-transport-critically-ill-patients-systematic … -
review-and
Transporting critically ill patients within a hospital (e.g., to radiology for diagnostic … procedures) is necessary
but also poses safety threats.
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psnet.ahrq.gov/issue/randomized-clinical-trial-compare-use-safety-net-enclosures-standard-restraints-agitated
September 07, 2022 - September 7, 2022
Patient safety in primary care: conceptual meanings to the health care … November 25, 2020
The association of acute COVID-19 infection with Patient Safety Indicator … improved patient safety outcomes: a stepped-wedge, cluster-randomised multicentre trial. … June 27, 2018
A case study on the safety impact of implementing smart patient-controlled … June 12, 2013
Risks related to patient bed safety.
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psnet.ahrq.gov/issue/patient-feedback-safety-improvement-primary-care-results-feasibility-study
December 02, 2020 - Study
Patient feedback for safety improvement in primary care: results from a feasibility … Patient feedback for safety improvement in primary care: results from a feasibility study. … This feasibility study surveyed 1,750 patients using the primary care patient measure of safety (PC … Patient feedback for safety improvement in primary care: results from a feasibility study. … July 21, 2021
How do patients respond to safety problems in ambulatory care?
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psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
June 24, 2010 - From a patient safety perspective, the single most effective method to avoid the adverse outcomes associated … Like most patient safety interventions, successful control of MRSA requires a combination of interventions … Certainly, the impact on patient safety is paramount, but there are potential financial implications … Like most patient safety activities, this requires a comprehensive approach focusing on the system and … Safety of patients isolated for infection control. JAMA. 2003;290:1899-1905.
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psnet.ahrq.gov/issue/medication-orders-future-start-dates-how-far-away-too-far
March 15, 2022 - Human errors that occur while interacting with electronic health record (EHR) systems can impact patients … August 9, 2023
Correct use of inhalers: help patients breathe easier. … safety. … March 12, 2014
Survey shows recession has weakened patient safety net. … Annual Perspective
Technology as a Tool for Improving Patient
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psnet.ahrq.gov/issue/avoiding-medical-emergencies
April 07, 2021 - how to assess and address risks in dental care and highlights checklists as a tool to help keep patients … safety. … April 1, 2020
The evolution of patient safety procedures in an oral surgery department … September 26, 2018
Patient safety incidents and adverse events in ambulatory dental care … October 5, 2016
Systematic review of patient safety interventions in dentistry.
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psnet.ahrq.gov/issue/nursing-management-medication-errors
November 02, 2022 - June 6, 2018
Patient and consumer safety risks when using conversational assistants for … October 4, 2017
The Daily Plan: including patients for safety's sake. … safety: a cross-sectional survey. … October 20, 2010
Nursing 2006 Patient-safety survey report. … July 26, 2010
Professional commitment, patient safety, and patient-perceived care quality
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psnet.ahrq.gov/issue/white-paper-recommendation-systems-based-practice-competency
December 18, 2017 - an adjunct to manual counting protocols for tracking surgical sponges: a prospective trial of 2,285 patients … , and patient outcomes. … August 28, 2017
Medication governance: preventing errors and promoting patient safety … November 5, 2013
Using the ABCs of situational awareness for patient safety. … June 6, 2012
Patient safety: planting the seed.
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psnet.ahrq.gov/issue/risk-factors-wrong-patient-medication-orders-emergency-department
June 08, 2022 - Findings indicate that RaR events are more likely when patients share the same sex and have exam rooms … safety: a systematic review. … a recurrence of patient safety incidents: an observational study. … November 9, 2015
Threats to patient safety in the primary care office: concerns of physicians … January 26, 2022
Patients' and healthcare workers' perceptions of a patient safety advisory
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psnet.ahrq.gov/issue/leadership-strategies-medical-school-deans-promote-quality-and-safety
August 10, 2022 - May 29, 2019
A scholarly pathway in quality improvement and patient safety. … November 19, 2018
Integrating patient safety education into early medical education utilizing … safety. … July 2, 2014
The incorporation of patient safety into board certification examinations … August 4, 2009
Integrating patient safety into curriculum.
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psnet.ahrq.gov/issue/preventing-harm-icu-building-culture-safety-and-engaging-patients-and-families
March 14, 2022 - Review
Preventing harm in the ICU—building a culture of safety and engaging patients … Preventing Harm in the ICU-Building a Culture of Safety and Engaging Patients and Families. … Preventing Harm in the ICU-Building a Culture of Safety and Engaging Patients and Families. … February 15, 2023
View More
Related Resources
AHRQ patient safety … November 16, 2011
Patient safety in the NICU: a comprehensive review.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.227_slideshow.ppt
November 01, 2010 - Describe current best practices for reducing patient safety risks associated with hospital discharge … safety and continuity of care. … Patient safety concerns arising from test results that return after hospital discharge. … safety awareness in general
Presence of electronic medical record
*
See Notes for references. … Successful TPAD management requires physicians to have high safety awareness and to use technology for
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psnet.ahrq.gov/issue/retrospective-cohort-study-wrong-patient-imaging-order-errors-how-many-reach-patient
February 22, 2023 - reach the patient? … Retrospective cohort study of wrong-patient imaging order errors: how many reach the patient? … Near misses (also referred to as close calls) represent important opportunities for safety improvement … Safety Databases. … June 16, 2019
WebM&M Cases
Speaking Up for Patient Safety
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psnet.ahrq.gov/issue/systematic-review-effectiveness-compliance-and-critical-factors-implementation-safety
December 04, 2024 - May 1, 2024
Electronic health record usability contributions to patient safety and clinician … a recurrence of patient safety incidents: an observational study. … January 11, 2023
Speaking up about patient safety in psychiatric hospitals - a cross-sectional … checklist on provider and patient outcomes: a systematic review. … September 11, 2013
Patient safety during anaesthesia: incorporation of the WHO safe surgery