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3341. ISMP medication error report analysis. | PSNet
      psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-32
      June 16, 2019 - This monthly selection reports on pump programming errors that led to overdoses of patient-controlled … View More See More About The Topic Hospitals Pharmacists Quality and Safety

3342. 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

3343. 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.

3344. When "Psychiatric" Symptoms Are Not | PSNet
      psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
      September 20, 2011 - The patient had been seen for many years through a local HMO and his records indicated no psychiatric … A friend of the patient’s reported the patient had believed for the past 5 to 7 years that the “shockers … In the 2 weeks prior to hospitalization, the patient reported they had somehow “upped the current.” … The patient used a walker for ambulation “because of pain.” … September 20, 2011 Perspective Patient Safety: A Perspective

3345. Spotlight: Mistaken Attribution, Diagnostic Misstep | PSNet
      psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
      July 01, 2011 - List the patient safety interventions that inpatient psychiatry units can implement to improve safety … Even though patient safety events are common in psychiatry and can harm patients, much of the foundational … Fortunately, the vast majority (95%) of patient safety events caused minimal or no harm. … The time is ripe for psychiatry to fully embrace the patient safety movement. … Defining patient safety events in inpatient psychiatry.

3346. Patient Safety and Adherence to Self-Administered Medications | PSNet
      psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
      September 29, 2011 - Patient Safety and Adherence to Self-Administered Medications Citation Text: Spall H, Van-Spall … Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. … Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. … Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. … September 29, 2011 Near-misses are an opportunity to improve patient safety: adapting

3347. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49699/psn-pdf
      February 01, 2014 - opioids on sedation and respiratory depression, differences between opioid-naïve and opioid-tolerant patients … To help them prevent errors, patients and families should be empowered to detect medication errors by … ISMP Medication Safety Alert! Community/Ambulatory Care Edition. … Pa Patient Saf Advis. 2013;10:27-33. [Available at] 8. ISMP Medication Safety Alert! … of patient input n quality improvement and safety initiatives Quality processes and risk management

3348. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33606/psn-pdf
      December 15, 2024 - This Primer will describe the nature of the opioid epidemic as a patient safety problem, discuss the … epidemiology of opioid prescribing and its resultant effects on patient safety and mortality, and review … research-topics/trends-statistics/overdose-death-rates#Fig3 https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem … The patient safety field was slow to recognize the burgeoning epidemic. … national-surveillance-emergency-department-visits-outpatient-adverse-drug-events https://psnet.ahrq.gov/primer/measurement-patient-safety

3349. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33561/psn-pdf
      September 15, 2024 - safety field. … However, when Never Events occur, they are devastating to patients and may indicate a fundamental safety … Sentinel events are defined as "a patient safety event (not primarily related to the natural course … These variations prevent comparisons and learning from the international patient safety community. … /primer/reporting-patient-safety-events https://psnet.ahrq.gov/issue/adverse-health-events-minnesota-

3350. Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart | PSNet
      psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
      October 30, 2024 - Innovation Patient Safety Focus Patient verification at the time of order entry helps to improve patient … safety by ensuring the right patient receives the right treatment. … Patient Safety Goal. 2 Orders entered into wrong chart:  Although multiple factors contribute to patient … National patient safety goals: hospital accreditation program. … Summary July 23, 2024 Patient Safety Innovations

3351. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861738/psn-pdf
      January 31, 2024 - Flexor tendons are more difficult to visualize during wound exploration.3 Approach to Patient Safety … However, there are several important management considerations that will improve patient safety and … Optimizing working conditions is critical to patient safety, and in this case may include adequate clinician … Barnes, MD, FACEP Consulting Editor, AHRQ, Patient Safety Network Health Sciences Clinical Professor … Safety of epinephrine in digital nerve blocks: a literature review.

3352. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33664/psn-pdf
      March 01, 2008 - safety. … RW: What data do you have that demonstrate that in fact this improves patient safety? … safety? … Not necessarily from a patient safety standpoint, but we have found that the decision of whether a line … In the real world I think that we have to find ways to maximize patient safety while taking into account

3353. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49469/psn-pdf
      December 01, 2004 - In doing so, the phlebotomist overrode the computerized alert that prompted him to be sure the patient … Once patients are adequately informed, how can we document that patient consent has or has not been … Nonetheless, protection of patient autonomy for many forms of genetic testing, or any procedure in which … reasonable people may have doubts about its safety or effectiveness, should receive priority. … reproductive and family issues arise and when the safety and effectiveness of the interventions that

3354. Do physicians clean their hands? Insights from a covert observational study. | PSNet
      psnet.ahrq.gov/issue/do-physicians-clean-their-hands-insights-covert-observational-study
      July 02, 2019 - June 21, 2017 Computerized prescriber order entry–related patient safety reports: analysis … August 31, 2016 Staying silent about safety issues: conceptualizing and measuring safety

3355. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33592/psn-pdf
      December 15, 2024 - safety field. … As the science of patient safety advances, these judgments can change over time, such that more adverse … assessment-adverse-events-medical-care-lack-consistency-between-experienced-teams-using https://psnet.ahrq.gov/issue/measurement-patient-safety-systematic-review-reliability-and-validity-adverse-event-detection … Two other terms define hazards to patients that do not result in harm: Near miss: an unsafe situation … act of commission (doing something wrong) or omission (failing to do the right thing) that exposes patients

3356. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49849/psn-pdf
      January 01, 2019 - List the patient safety interventions that inpatient psychiatry units can implement to improve safety … Even though patient safety events are common in psychiatry and can harm patients, much of the foundational … Fortunately, the vast majority (95%) of patient safety events caused minimal or no harm. … The time is ripe for psychiatry to fully embrace the patient safety movement. … Defining patient safety events in inpatient psychiatry.

3357. A Statewide Collaborative to Support Vaginal Birth and Reduce Unnecessary Cesarean Deliveries | PSNet
      psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
      July 23, 2024 - Innovation Patient Safety Focus High rates of cesarean delivery are a concern in the United States … A multi-pronged patient safety bundle that includes a toolkit for clinicians and educational resources … A multi-pronged patient safety bundle that includes a toolkit for clinicians and educational resources … Patient Safety Innovations Preventing Falls Through … September 29, 2010 Improving patient safety with team coordination: challenges and strategies

3358. Poorly Advanced Directives | PSNet
      psnet.ahrq.gov/web-mm/poorly-advanced-directives
      August 01, 2018 - Patients or surrogates complete the form in discussion with their provider, and the patient or surrogate … Advance directives for seriously ill hospitalized patients: effectiveness with the patient self-determination … safety and medical fallibility. … March 30, 2022 Patient safety, systems design and ergonomics. … June 21, 2006 An improved patient safety reporting system increases reports of disruptive

3359. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49612/psn-pdf
      November 01, 2010 - Describe current best practices for reducing patient safety risks associated with hospital discharge. … Consequently, patient care suffers, and often, patients recently discharged return to the hospital for … safety awareness manage pending tests more effectively. … safety and continuity of care. … Patient safety concerns arising from test results that return after hospital discharge.

3360. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33854/psn-pdf
      March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety March 1, 2018 Ball JE, Griffiths P. … Missed Nursing Care: A Key Measure for Patient Safety. PSNet [internet]. 2018. … https://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety Perspective Errors … in hospitals remain a major cause of death.(1) Many patient safety initiatives focus on reducing the … safety grades reported by nurses.(4) Where missed care rates are higher, patients are less likely to