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psnet.ahrq.gov/issue/spike-fatal-medication-errors-beginning-each-month
January 26, 2022 - Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety … June 9, 2011
Effect of genetic diagnosis on patients with previously undiagnosed disease … All consumer medication information is not created equal: implications for medication safety … March 27, 2013
Diagramming patients' views of root causes of adverse drug events in ambulatory
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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/node/60066/psn-pdf
March 25, 2020 - changes, and to advocate for patients’ safety. … In July 2019, TJC began requiring EDs to screen
all patients for suicide risk (National Patient Safety … Take Home Points
ED crowding is a major problem that threatens patient safety. … Human factors analysis in patient safety systems. The Source. Volume 13,
Issue 4, April 2015.
7. … Teams, tribes and patient safety: overcoming barriers to effective
teamwork in healthcare.
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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/web-mm/unfamiliar-catheter
November 01, 2006 - Swayze, RN, MA Senior Project Manager for Communications Patient Safety Staff Partnerships/MedSun … An organizational approach to understanding patient safety and medical errors. … Patient Safety and Quality: An Evidenced-based Handbook for Nurses. … October 28, 2020
Patient safety: a consumer's perspective. … December 4, 2016
Annual Perspective
Equity in Patient Safety
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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/web-mm/monitoring-fetal-health
September 08, 2010 - Appreciate the importance of safety culture on labor and delivery units. … They compromise safety and can result in fatalities. … This complicated patient flow requires dedicated specialized teams with strong commitment to safety. … Learning from patient-reported incidents. … safety in obstetrics and gynecology.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
October 01, 2011 - activity (e.g., post-operative setting)
Safe monitoring of response to therapy (e.g., physiological safety … Early activity is feasible and safe in respiratory failure patients. … Managing the patient on mechanical ventilation in ICU: early mobility and walking program. … Managing the patient on mechanical ventilation in ICU: early mobility and walking program. … Managing the patient on mechanical ventilation in ICU: early mobility and walking program.
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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/node/73901/psn-pdf
September 29, 2021 - and pharmacists reviewing
relevant clinical electronic health record (EHR) data for all hospitalized patients … Using the Safer Dx instrument, the research team retrospectively reviewed patient electronic health record … antimicrobial-stewardship
https://psnet.ahrq.gov/issue/using-good-catches-promote-just-culture-and-perioperative-patient-safety
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psnet.ahrq.gov/issue/association-state-opioid-duration-limits-postoperative-opioid-prescribing
April 18, 2019 - April 18, 2019
Persistent opioid use among pediatric patients after surgery. … August 4, 2021
View More
Related Resources
Fire safety in the operating … 11, 2024
Evaluation of policies limiting opioid exposure on opioid prescribing and patient … March 10, 2021
WebM&M Cases
Fatal Patient-Controlled … Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety
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psnet.ahrq.gov/issue/implementation-communication-didactics-obgyn-residents-disclosure-adverse-perioperative
July 21, 2021 - Medical residents are frequently involved in difficult patient conversations, including error disclosure … July 21, 2021
Chief resident indirect supervision in training safety study: is a chief … resident general surgery service safe for patients? … August 18, 2021
We asked the experts: the WHO Surgical Safety Checklist and the COVID … November 9, 2022
More than words: patients' views on apology and disclosure when things
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psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
September 01, 2011 - of the University of Toronto Centre for Patient Safety. … reviewing medical records or applying patient safety indicators to discharge data.( 5,9 ) Second, increasing … New patient safety organizations can help health providers learn from and reduce patient safety events … J Patient Saf. 2009;5:1-2. [go to PubMed]
4. Patient Safety Organizations. … Legal concerns in patient safety: the need for regulatory action.
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psnet.ahrq.gov/node/49677/psn-pdf
February 01, 2013 - has been shown to increase trainees' level of comfort and perceived
readiness for attempts on real patients … Making Health Care Safer: a Critical Analysis of Patient Safety Practices: Summary. … Phase I of the
Procedural Patient Safety Initiative. J Gen Intern Med. 2006;21:514-517. … Phase II of the
Procedural Patient Safety Initiative (PPSI-II). J Hosp Med. 2009;4:423-429. … Proceduralists—leading patient safety initiatives. N Engl J Med. 2007;356:1789-
1790.
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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - The patient
remained stable. … Incidence of adverse events and negligence in hospitalized
patients. … The nature of adverse events in hospitalized patients. … Improving patient safety by identifying side effects from introducing
bar coding in medication administration … cmd=Retrieve&db=PubMed&list_uids=10718351&dopt=Abstract
https://www.jointcommission.org/resources/patient-safety-topics
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psnet.ahrq.gov/primer/falls
October 27, 2021 - Of course, some of these may represent patient safety issues if, for example, a sedating medication was … Current Context Fall prevention is a National Patient Safety Goal for both hospitals and long-term … Safety Primers
Deprescribing as a Patient Safety Strategy October 27, 2021
Long-term Care … and Patient Safety April 10, 2024
Nursing and Patient Safety April 21, 2021
Editor's … Patient Safety
April 10, 2024
Patient Safety Innovations
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - encountered during the analytic phase typically resides with improper instrument operation, faulty reagents … April 18, 2018
Wake Up Safe in the USA & international patient safety. … August 7, 2024
Status of patient safety culture in community pharmacy settings: a systematic … August 23, 2023
Interventions to engage patients and families in patient safety: a systematic … implications of missed test results for hospitalised patients: a systematic review.
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psnet.ahrq.gov/issue/ashp-national-survey-pharmacy-practice-hospital-settings-dispensing-and-administration-2011
September 30, 2020 - 1400 hospitals by the American Society of Health-System Pharmacists found that uptake of medication safety … 2022
ASHP national survey of pharmacy practice in hospital settings: monitoring and patient … 2017
ASHP national survey of pharmacy practice in hospital settings: monitoring and patient … September 23, 2020
Effect of bar-code technology on the safety of medication administration … December 23, 2016
Intravenous infusion safety technology: return on investment.
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psnet.ahrq.gov/issue/reducing-rate-catheter-associated-bloodstream-infections-surgical-intensive-care-unit-using
November 16, 2022 - October 12, 2022
Teamwork, communication and safety climate: a systematic review of interventions … Building the bridge to quality: an urgent call to integrate quality improvement and patient … safety education with clinical care
October 2, 2019
Realistic distractions and interruptions … February 7, 2022
AHRQ patient safety project reduces bloodstream infections by 40 percent
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psnet.ahrq.gov/issue/education-initiatives-cognitive-debiasing-improve-diagnostic-accuracy-student-providers
October 21, 2020 - January 26, 2022
Developing the Safer Dx Checklist of Ten Safety Recommendations for … June 21, 2023
Annual Perspective
Improving Diagnostic Safety … September 16, 2020
Incoming interns recognize inadequate physical examination as a cause of patient … A qualitative study of emotions, triggers, regulation strategies, and effects on patient care. … October 30, 2019
Controversies in diagnosis: contemporary debates in the diagnostic safety