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psnet.ahrq.gov/node/38759/psn-pdf
April 05, 2010 - This mixed methods study
evaluates the first phase of the project by soliciting the perceptions of project
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psnet.ahrq.gov/issue/ashp-iv-adult-continuous-infusions
February 08, 2006 - Representing the first phase of a standards development project , this report describes how standardization
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psnet.ahrq.gov/issue/using-implementation-safety-indicators-cpoe-implementation
August 04, 2021 - CPOE) system, and makes recommendations about the importance of monitoring during the implementation phase
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psnet.ahrq.gov/node/41280/psn-pdf
December 31, 2014 - hospitals to assess the degree to
which monitoring devices and other information displays supported each phase
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psnet.ahrq.gov/node/36357/psn-pdf
December 19, 2009 - Error reporting in organizations.
December 19, 2009
Zhao B; Olivera F. Acad Manag Rev. 2006;31(4):1012-1030.
https://psnet.ahrq.gov/issue/error-reporting-organizations
The authors provide a framework for individual error reporting behavior that follows three phases: error
detection, situation assessment, and choic…
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psnet.ahrq.gov/node/44506/psn-pdf
October 21, 2015 - feedback of current hygiene compliance rates resulted in an increase that lasted throughout the
study phase
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psnet.ahrq.gov/node/43170/psn-pdf
December 12, 2014 - high-alert medication uses had
errors, with more occurring in the prescribing than the administration phase
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psnet.ahrq.gov/sites/default/files/2021-09/Battle%20Buddy%20Pocket%20Card%20-%20final%20(1).pdf
January 01, 2021 - Please move into the Deter phase by seeking or
helping your BB to connect with your dedicated mental
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psnet.ahrq.gov/node/73998/psn-pdf
October 27, 2021 - During the first phase, team
members are asked whether there is a risk of blood loss greater than 500 … During the second communication phase, the surgeon is asked to confirm the
anticipated blood loss and … all checklist points are thoroughly discussed, and concerns addressed, before
proceeding to the next phase
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psnet.ahrq.gov/node/40232/psn-pdf
February 23, 2011 - In this phase one
study, the SPI focused efforts in 4 hospitals, where a $1.2 million investment was
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psnet.ahrq.gov/node/40565/psn-pdf
June 29, 2011 - The administration phase was the most error-prone, and the most common error type was improper
dose/
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psnet.ahrq.gov/node/39501/psn-pdf
January 03, 2017 - 300,000 medication events
reported, approximately 4% involved heparin products, with the administration phase
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psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation-newsletter
August 14, 2019 - August 8, 2018
Critical phase distractions in anaesthesia and the sterile cockpit concept
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psnet.ahrq.gov/web-mm/lost-transition
November 17, 2010 - In the pre-transition phase, the ED doctors were content with the diagnosis of urinary infection as the … time-dependent outcomes invariably rely on many individual processes and interactions; the transition phase
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psnet.ahrq.gov/node/36943/psn-pdf
May 08, 2018 - Remote CPOE error—a situation that's more than
remotely possible.
May 8, 2018
ISMP Medication Safety Alert! Acute Care Edition. May 31, 2007;12:1-3.
https://psnet.ahrq.gov/issue/remote-cpoe-error-situation-thats-more-remotely-possible
This article describes a wrong-patient drug error that was prescribed using a co…
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psnet.ahrq.gov/issue/toolkits-reduce-hypertension-pregnancy-and-obstetric-hemorrhage
August 01, 2012 - The AHRQ Safety Program for Perinatal Care , Phase 2 developed toolkits consisting of case scenarios
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psnet.ahrq.gov/issue/exploration-automated-approach-receiving-patient-feedback-after-outpatient-acute-care-visits
September 07, 2011 - Study
Exploration of an automated approach for receiving patient feedback after outpatient acute care visits.
Citation Text:
Berner ES, Ray MN, Panjamapirom A, et al. Exploration of an automated approach for receiving patient feedback after outpatient acute care visits. J Gen Intern Med.…
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psnet.ahrq.gov/node/39116/psn-pdf
April 30, 2014 - embolism and drug reactions or overdose, with the errors occurring
most frequently in the testing phase
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psnet.ahrq.gov/node/45533/psn-pdf
November 02, 2016 - The next
phase involved giving health systems financial incentives to report their data on harm-free
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psnet.ahrq.gov/issue/pharmacist-led-educational-interventions-provided-healthcare-providers-reduce-medication
October 14, 2020 - The phase, educational strategy , patient population, and audience varied across studies; however most