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psnet.ahrq.gov/issue/prescriber-barriers-and-enablers-minimising-potentially-inappropriate-medications-adults
September 23, 2020 - These findings emphasize the need for fundamental health care reform in order to improve medication safety … , 2012
Evidence review conducted for the Agency for Healthcare Research and Quality Safety … August 2, 2015
Improving infusion pump safety through usability testing. … May 31, 2017
Optimizing Pediatric Patient Safety in the Emergency Care Setting. … July 26, 2011
Randomized trial to improve prescribing safety during pregnancy.
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - safety culture? … July 14, 2021
Clinical efficacy of combined surgical patient safety system and the World … April 12, 2019
Development of patient safety measures to identify inappropriate diagnosis … residents based on experiential knowledge related to patient safety culture at the nursing home front … of patients in intensive care units.
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psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
February 01, 2010 - We asked him to speak with us about the role of the ACGME in patient safety.
Dr. … We have dual responsibilities not only for the safety of patients in the training environment, but also … Perspective
“Patient safety always has been, and remains our prime directive.” … Residency training is an extraordinarily important area for patient safety. … [go to PubMed]
23. 2010 National Patient Safety Goals (NPSGs). The Joint Commission.
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-adults
April 10, 2024 - Various factors associated with COVID-19 that negatively impacted patient safety and resulted in poor … Professional organizations have also supported higher NH staffing to improve patient safety and quality … Safety Primers
Long-term Care and Patient Safety April 10, 2024
Discharge Planning and Transitions … March 1, 2014
Telemedicine and Patient Safety September 1, 2016
Related Resources … August 17, 2022
Patient Safety Primers
Nursing and Patient
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psnet.ahrq.gov/issue/incidence-opioid-misuse-among-surgical-patients-persistent-opioid-use
October 13, 2018 - safety concern . … October 13, 2018
Patient outcomes after opioid dose reduction among patients with chronic … 14, 2020
Evaluation of policies limiting opioid exposure on opioid prescribing and patient … December 21, 2022
Factors causing variation in World Health Organization surgical safety … August 5, 2020
WebM&M Cases
Fatal Patient-Controlled
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psnet.ahrq.gov/issue/cost-effectiveness-computerized-provider-order-entry-system-improving-medication-safety
August 09, 2017 - Cost-effectiveness of a computerized provider order entry system in improving medication safety … Cost-Effectiveness of a Computerized Provider Order Entry System in Improving Medication Safety Ambulatory … implementation of electronic prescribing to estimate the benefit of CPOE for outpatient medication safety … August 9, 2017
Optimizing Pediatric Patient Safety in the Emergency Care Setting. … January 19, 2014
E-prescribing: a focused review and new approach to addressing safety
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psnet.ahrq.gov/issue/profit-long-term-care-homes-and-risk-covid-19-outbreaks-and-resident-deaths
October 28, 2020 - October 5, 2022
Ethical considerations and patient safety concerns for cancelling non-urgent … October 12, 2022
Patient Safety Primers
Coronavirus Disease … 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes
February 24, 2022 … April 14, 2021
Coronavirus Commission for Safety and Quality in Nursing Homes.
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psnet.ahrq.gov/issue/burnout-and-medical-errors-among-american-surgeons
December 21, 2014 - Duty-hour restrictions for resident physicians are intended to improve safety, but research in residents … February 2, 2011
Physician burnout, well-being, and work unit safety grades in relationship … December 21, 2018
Physicians' experiences with mistreatment and discrimination by patients … of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients … March 28, 2011
Attitudes to teamwork and safety in the operating theatre.
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psnet.ahrq.gov/issue/acr-recommendations-use-chest-radiography-and-computed-tomography-ct-suspected-covid-19
August 14, 2019 - Delayed diagnosis of COVID-19 may lead to worse patient outcomes and increased exposure of healthy individuals … August 14, 2019
Joint Statement on Multiple Patients Per Ventilator. … June 16, 2021
Patient Safety Recommendations for COVID-19 Epidemic Outbreak: 3.0 … December 16, 2020
Patient safety concerns in COVID-19–related events: a study of 343 … May 20, 2020
Joint Statement on Multiple Patients Per Ventilator.
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psnet.ahrq.gov/issue/impact-type-manual-medication-cart-filling-method-frequency-medication-administration-errors
January 23, 2019 - transitional pharmaceutical care program on the occurrence of ADEs after discharge from hospital in patients … August 18, 2010
View More
Related Resources
Patient … Safety Primers
Medication Administration Errors
March 12, 2021 … December 10, 2014
Adverse drug events in hospitalized cardiac patients. … About The Topic
General Hospitals
Nurses
Pharmacists
Nurse Managers
Quality and Safety
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.311_slideshow.ppt
December 01, 2013 - Efficacy and safety of novel oral anticoagulants for treatment of acute venous thromboembolism: direct … Efficacy and safety of novel oral anticoagulants for treatment of acute venous thromboembolism: direct … in this situation:
The limited clinical experience with TSOACs among many clinicians
The lack of a "safety … informing clinicians that thromboembolism risk increases with abrupt discontinuation
19
MedWatch Safety … Available at http://www.fda.gov/Safety/MedWatch/SafetyInformation/ucm250657.htm
19
Common Potential
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psnet.ahrq.gov/node/867035/psn-pdf
October 30, 2024 - A
2024 National Patient Safety Goal set forth by The Joint Commission is to “reduce the likelihood of … /psnet.ahrq.gov//%2420
https://psnet.ahrq.gov//#21
https://psnet.ahrq.gov//#22
https://www.ahrq.gov/patient-safety … Proactively ensuring
environmental safety for patients who are not able to call for assistance would … Inpatient fall prevention programs as a patient safety
strategy: a systematic review. … The Joint Commission. 2024 Hospital National Patient Safety Goals. Accessed July 5, 2024.
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psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
January 01, 2021 - called the hospital’s
patient safety officer
– In her native language, the patient said that while … Safety
17
18
Approach to Improving Patient Safety (1)
• Retained vaginal packing results from a … Safety (5)
• The armband serves as a reminder for the patient care nurses to
remove the packing or … Safety (6)
• At each handoff and as care progresses, nurses can remind the
patient why the armband … safety.
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psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - Bourgeois, OD, MD
Consulting Editor, AHRQ, Patient Safety Network (PSNet)
Vice Chair, Hospital Service … Are verbal orders a threat to patient safety?. Qual Saf Health Care.
2009;18(3):165-168. … department patients with acute agitation. … doi.org/10.1093/ajhp/zxab325
https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/patient-safety … /patient-safety-practice-resource-for-automated-dispensing-cabinet-overrides.ashx
https://doi.org/10.2146
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psnet.ahrq.gov/node/49851/psn-pdf
January 01, 2019 - psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
In an effort to improve bronchoscopy safety … The British Thoracic Society's recommended bronchoscopy safety checklist is adapted from the World
Health … Organization (WHO) surgical safety checklist (6), and it is divided into three checkpoint sections: … As encouraged by the guideline, each institution should make
modifications and additions to the WHO safety … British Thoracic Society's Recommended Bronchoscopy Safety Checklist.(3) Click on
thumbnail for PDF
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psnet.ahrq.gov/print/pdf/node/866100
August 30, 2023 - Safety
Curated Library
Foundations
Keeping Patients Safe: Transforming the Work Environment of Nurses … patient safety risks such as misdiagnosis. … patient safety risks such as misdiagnosis. … https://psnet.ahrq.gov/issue/magnet-support-patient-safety
https://psnet.ahrq.gov/issue/ten-years-after-keeping-patients-safe-have-nurses-work-environments-been-transformed … Keeping Patients Safe: Transforming the Work Environment of Nurses.
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psnet.ahrq.gov/node/49737/psn-pdf
June 01, 2015 - table
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
improve the quality and safety … of patient care. … The nurse reported that the patient had not voided in
2 hours, but history notes the patient is incontinent … Assist in healing of open sacral/perineal wound in incontinent patients. … products in male and female patients with urinary incontinence.
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psnet.ahrq.gov/web-mm/no-bp-during-nibp
March 01, 2011 - Hence, a stale blood pressure alert would likely decrease patient safety instead of improving it. … Older devices with less safety enhancements are often relegated to non-operating room settings. … This may pose safety hazards. … The risk and safety of anesthesia at remote locations: the US closed claims analysis. … Risk and safety of anesthesia outside the operating room. Minerva Anestesiol. 2009;75:345-348.
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psnet.ahrq.gov/issue/effect-delays-2-week-wait-cancer-referral-pathway-during-covid-19-pandemic-cancer-survival-uk
October 21, 2020 - proportion of patients with early-stage tumors progressing from having curable to incurable disease. … Changes to primary care delivery during the COVID-19 pandemic and perceived impact on medication safety … June 29, 2022
Concordance with urgent referral guidelines in patients presenting with … November 25, 2020
User-testing guidelines to improve the safety of intravenous medicines … June 17, 2020
Safety at the time of the COVID-19 pandemic: how to keep our oncology patients
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psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
May 01, 2011 - Evaluation of medication list completeness, safety, and annotations. … Patient safety reporting systems: sustained quality improvement using a multidisciplinary team and "Good … safety. … Safety Primers
Deprescribing as a Patient Safety Strategy
October 27, 2021 … July 1, 2019
The compliance with a patient safety bundle for management of placenta accreta