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psnet.ahrq.gov/node/44104/psn-pdf
July 16, 2015 - wrong-site-wrong-procedure-and-wrong-patient-surgery
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
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psnet.ahrq.gov/node/46894/psn-pdf
June 20, 2018 - ashp-iv-adult-continuous-infusions
https://psnet.ahrq.gov/issue/infusion-medication-error-reduction-two-person-verification-quality-improvement-initiative
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - complexity increased, something not seen with written orders.(5)
Sending Messages Through a Third Person … Multitasking"
Another possible contributing factor here was the transmission of the order via a third person … Communicating through a third person while "multitasking" not only increases the risk of
miscommunication … safety procedures such as warnings, limiting medication amounts, special labeling and packaging, second
person
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psnet.ahrq.gov/web-mm/40-k
January 12, 2011 - complexity increased, something not seen with written orders.( 5 ) Sending Messages Through a Third Person … Multitasking" Another possible contributing factor here was the transmission of the order via a third person … Communicating through a third person while "multitasking" not only increases the risk of miscommunication … safety procedures such as warnings, limiting medication amounts, special labeling and packaging, second person
-
psnet.ahrq.gov/node/34065/psn-pdf
February 09, 2011 - Incidence and preventability of adverse drug events
among older persons in the ambulatory setting. … Incidence and Preventability of Adverse Drug Events Among Older
Persons in the Ambulatory Setting. … https://psnet.ahrq.gov/issue/incidence-and-preventability-adverse-drug-events-among-older-persons-
ambulatory-setting … The overall rate of adverse drug events approached 50 per 1000 person-years
with the most serious events … https://psnet.ahrq.gov/issue/incidence-and-preventability-adverse-drug-events-among-older-persons-ambulatory-setting
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psnet.ahrq.gov/node/35540/psn-pdf
August 05, 2009 - The authors define handoffs as "any transfer of role and responsibility
from one person to another."
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psnet.ahrq.gov/node/36632/psn-pdf
July 28, 2010 - incidence-patterns-and-prevention-wrong-site-surgery
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
-
psnet.ahrq.gov/node/36833/psn-pdf
March 03, 2011 - incidence-patterns-and-prevention-wrong-site-surgery
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
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psnet.ahrq.gov/issue/no-place-home-advancing-safety-care-home
January 09, 2019 - document outlines five guiding principles to enhance safety of home care, which include a focus on person-centered
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psnet.ahrq.gov/node/49541/psn-pdf
August 21, 2007 - incorporation of the Joint
Commission's "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person … A "time-out" should be
conducted to confirm the above using the two-person rule. … procedure to verify patient, tooth, and procedure
with the assistant at the time of extraction (two-person
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psnet.ahrq.gov/node/43363/psn-pdf
September 12, 2016 - Similar to studies of handoffs, direct conversation—either in
person or via mobile phone—was deemed
-
psnet.ahrq.gov/node/43393/psn-pdf
July 30, 2014 - effectiveness-surgical-safety-checklist-correcting-errors-literature-review-applying-reasons
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
-
psnet.ahrq.gov/node/40020/psn-pdf
September 20, 2011 - language-proficiency-and-adverse-events-us-hospitals-pilot-study
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
-
psnet.ahrq.gov/node/38949/psn-pdf
January 28, 2010 - timeouts
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
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psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
February 01, 2006 - What do you do if the person becomes hysterical or enraged? … We can all recognize this person, and while I am told they are still around, I rarely meet one. … It is not that this person wants to seem distant or uncaring, or rude or arrogant. … This is a person who has forgotten how to listen, who is used to dominating conversations, who interrupts … At lunch, I said to this person, who I thought was a physician, "I have a hunch I didn't convince you
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psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd
February 01, 2006 - We can all recognize this person, and while I am told they are still around, I rarely meet one. … It is not that this person wants to seem distant or uncaring, or rude or arrogant. … This is a person who has forgotten how to listen, who is used to dominating conversations, who interrupts … At lunch, I said to this person, who I thought was a physician, "I have a hunch I didn't convince you … What do you do if the person becomes hysterical or enraged?
-
psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
June 24, 2010 - While invasive MRSA infections occur more commonly in the hospital, 15% occurred in persons without any … reservoir for MRSA in health care facilities, and the predominant method of transmission occurs from person … to person via the hands of health care personnel. … 13 times more likely to develop a more resistant strain of CA-MRSA.( 14 ) Since CA-MRSA is spread by person-to-person
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psnet.ahrq.gov/node/34732/psn-pdf
May 09, 2015 - First stories are the easy one-person or one-cause accounts and
reactions to critical incidents.
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psnet.ahrq.gov/node/44626/psn-pdf
November 04, 2015 - begins
with a preliminary investigation into what happened and who was involved, followed by an in-person
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psnet.ahrq.gov/node/35868/psn-pdf
July 10, 2008 - incidence-patterns-and-prevention-wrong-site-surgery
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery