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3321. One Dose, Two Errors | PSNet
      psnet.ahrq.gov/web-mm/one-dose-two-errors
      September 29, 2017 - The patient safety movement has taught us that all manner of errors—including entering errors on the … of continuous improvement and patient safety that involves and is embraced by all health care workers … Leadership, safety climate, and continuous quality improvement: impact on process quality and patient … safety. … September 22, 2021 Optimizing Pediatric Patient Safety in the Emergency Care Setting.

3322. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures | PSNet
      psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
      November 27, 2019 - There was no mention of abdominal wall varices, but this is a common pitfall in operating on patients … CPR often needs to be paused in the setting of acute ATLS procedures in order to ensure safety. … June 19, 2024 Frontline providers' and patients' perspectives on improving diagnostic … safety in the emergency department: a qualitative study. … July 12, 2023 The Psychological Safety Scale of the Safety, Communication, Operational

3323. African Partnerships for Patient Safety: Lessons Learned | PSNet
      psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
      December 01, 2014 - Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients … National patient safety policy 2. Knowledge and learning in patient safety 3. … Patient safety awareness 4. Health services for patient safety 5. … and our Patients for Patient Safety program . … March 16, 2023 Failure to rescue as a patient safety indicator for neurosurgical patients

3324. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73874/psn-pdf
      September 29, 2021 - generalizability-medication-administration-discrepancy-detection-system-quantitative Medication administration errors are a common source of patient … Phenotyping for patient safety: algorithm development for electronic health record based automated adverse … computerized-dose-range-checking-using-hard-and-soft-stop-alerts-reduces-prescribing-errors https://psnet.ahrq.gov/issue/are-verbal-orders-threat-patient-safety

3325. The generalizability of a medication administration discrepancy detection system: quantitative comparative analysis | PSNet
      psnet.ahrq.gov/innovation/generalizability-medication-administration-discrepancy-detection-system-quantitative
      November 04, 2020 - Phenotyping for patient safety: algorithm development for electronic health record based automated adverse … different interventions to help primary care clinicians avoid unsafe opioid prescribing in opioid-naive patients … December 4, 2019 View More Related Resources Patient … Patient Safety Innovations Remote Response Team and Customized … 2023 Journal Article Study Patient

3326. Do junior doctors make more prescribing errors than experienced doctors when prescribing electronically using a computerised physician order entry system combined with a clinical decision support system? A cross-sectional study. | PSNet
      psnet.ahrq.gov/issue/do-junior-doctors-make-more-prescribing-errors-experienced-doctors-when-prescribing
      February 22, 2023 - February 22, 2023 Do patients' disruptive behaviours influence the accuracy of a doctor's … September 14, 2022 View More Related Resources Comparing safety … , performance and user perceptions of a patient-specific indication-based prescribing tool with current … May 27, 2011 Potassium and phosphorus repletion in hospitalized patients: implications … safety.

3327. Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula | PSNet
      psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
      February 01, 2019 - safety, interprofessional education) and GME (e.g., quality improvement, patient safety) curricula. … safety issues across the continuum for individual patients and populations of patients are critical … Boston, MA: National Patient Safety Foundation; 2015. [Available at] 5. … Create centralized and coordinated oversight of patient safety 3. … Increase funding for research in patient safety and implementation science 5.

3328. Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer | PSNet
      psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
      February 26, 2025 - The Brigham and Women’s Hospital’s (BWH) Patient Safety Collaborative, which included Ambulatory Patient … a colonoscopy following safety net team outreach to the patient and (2) the proportion of patients for … 56.9% when accounting for the proportion of patients who were effectively caught by the safety net by … outreach via a clinic-determined method (hard copy letters, phone calls to client, or outreach to patient … Identify drivers of change to ensure patient safety and to minimize patient harm.

3329. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74022/psn-pdf
      March 01, 2021 - The Role of Community Pharmacists in Patient Safety October 25, 2021 Luchen GG, Hall KK, Hough KR. … The Role of Community Pharmacists in Patient Safety . PSNet [internet]. 2021. … https://psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety What is a community pharmacy … Patient safety is best achieved in organizations that have a strong culture of safety. … Organizations with a strong culture of safety are not only better positioned to ensure patient safety

3330. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49778/psn-pdf
      December 01, 2016 - However, the resident had been caring for both patients, and he mistakenly entered the amphotericin … The patient safety movement has taught us that all manner of errors—including entering errors on the … safety is for hospitals to establish and support a culture of continuous improvement and patient safety … Leadership, safety climate, and continuous quality improvement: impact on process quality and patient … safety.

3331. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33570/psn-pdf
      June 15, 2024 - Background The past decade's quest to improve patient safety has chiefly addressed quantifiable problems … Diagnostic error has received comparatively less attention, despite the fact that landmark patient safety … /psnet.ahrq.gov/issue/using-medical-malpractice-closed-claims-data-reduce-surgical-risk-and-improve-patient-safety … https://psnet.ahrq.gov/issue/improving-diagnosis-health-care https://psnet.ahrq.gov/primer/reporting-patient-safety-events … https://psnet.ahrq.gov/primer/culture-safety https://psnet.ahrq.gov/primer/measurement-patient-safety

3332. CDC guideline for prescribing opioids for chronic pain—United States, 2016. | PSNet
      psnet.ahrq.gov/issue/cdc-guideline-prescribing-opioids-chronic-pain-united-states-2016
      June 14, 2019 - These guidelines do not apply to patients receiving cancer treatment, palliative care, or end-of-life … June 14, 2019 Indication-specific opioid prescribing for US patients with Medicaid or … August 2, 2017 Urban outpatient views on quality and safety in primary care. … July 13, 2010 View More Related Resources Medication guides: patient … June 28, 2018 FDA Drug Safety Communication: FDA requires labeling changes for prescription

3333. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33753/psn-pdf
      August 22, 2013 - Recent evidence shows that roughly one in three hospitalized patients experiences an adverse event, and … culture deliver better care because they are able to do the basics every time, like turning patients … The Essential Guide for Patient Safety Officers, 2nd edition. … Committee on Patient Safety and Health Information Technology, Board on Health Care Services, Institute … Health IT and Patient Safety: Building Safer Systems for Better Care.

3334. Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes | PSNet
      psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
      July 23, 2024 - Innovation Patient Safety Focus This innovation uses core patient safety communication and teamwork … births. 10   Improved task completion, medication administration, and response times for eclampsia patients … : A randomized controlled trial (RCT) focused on the care of patients with eclampsia found that PROMPT … Patient Safety Innovations Risk Mitigation Using the … August 16, 2023 Psychological intervention to improve communication and patient safety

3335. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851389/psn-pdf
      July 31, 2023 - The Brigham and Women’s Hospital’s (BWH) Patient Safety Collaborative, which included Ambulatory Patient … a colonoscopy following safety net team outreach to the patient and (2) the proportion of patients … 56.9% when accounting for the proportion of patients who were effectively caught by the safety net by … outreach via a clinic-determined method (hard copy letters, phone calls to client, or outreach to patient … Identify drivers of change to ensure patient safety and to minimize patient harm.

3336. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head | PSNet
      psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
      March 27, 2024 - About three weeks later, the patient saw his primary care physician (PCP), still complaining of ongoing … Critique of Patient Care The acute management of this patient at the time of his first presentation seems … After this patient’s follow-up with his PCP, the patient had worsening headaches (as indicated by his … ' and doctors' views and experiences of the patient safety trajectory of breast cancer care. … safety.

3337. Standard Deviations | PSNet
      psnet.ahrq.gov/web-mm/standard-deviations
      January 01, 2006 - Case Objectives Understand the safety risks associated with patients being discharged against medical … From the perspective of patient safety, this case emphasizes how important it is to focus on our competencies … Outreach workers spend months trying to develop trusting relationships with homeless clients and even … Patients whom staff find difficult to like, or care for, are vulnerable to safety risks created by reduced … November 5, 2014 Nurse judgements of hospitalized patients' safety concerns are affected

3338. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists | PSNet
      psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
      February 26, 2025 - Safety February 26, 2025 Perspective Learning … Health Systems for Patient Safety February 26, 2025 Estimating breast cancer … September 2, 2020 Why is safety in intrapartum electronic fetal monitoring so hard? … February 7, 2024 Patient safety and the COVID-19 pandemic: a qualitative study of perspectives … May 15, 2024 View More Related Resources Patient Safety

3339. Using medication containers during pharmacist transitional care visits and impact on medication discrepancies identified and hospital readmission risk. | PSNet
      psnet.ahrq.gov/issue/using-medication-containers-during-pharmacist-transitional-care-visits-and-impact-medication
      March 08, 2023 - compared with patients who did not. … December 2, 2020 Surgeon burnout, impact on patient safety and professionalism: a systematic … March 16, 2022 Patient errors in use of injectable antidiabetic medications: a need for … Interdisciplinary collaboration across secondary and primary care to improve medication safety … November 30, 2022 Understanding factors that could influence patient acceptability of

3340. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60269/psn-pdf
      April 29, 2020 - Identifying Risks to Patient Safety In the presented case, there were undoubtedly multiple failures … Burnout affects not only the physician experience, but also patient safety and outcomes. … Physician burnout demands attention both as an underlying cause of decreased patient safety as well … Patient Safety Network. https://psnet.ahrq.gov/primer/burnout. Updated September, 2019. … Understanding Patient Safety. Third Edition: McGraw-Hill Education, China; 2018.