-
psnet.ahrq.gov/node/38861/psn-pdf
August 26, 2009 - Survey evaluation of the National Patient Safety Agency’s
Root Cause Analysis training programme in England and
Wales: knowledge, beliefs and reported practices.
August 26, 2009
Wallace LM, Spurgeon P, Adams S, et al. Survey evaluation of the National Patient Safety Agency's Root
Cause Analysis training programme …
-
psnet.ahrq.gov/node/850166/psn-pdf
June 07, 2023 - Classification of health information technology safety
events in a pediatric tertiary care hospital.
June 7, 2023
Khan A, Karavite DJ, Muthu N, et al. Classification of health information technology safety events in a
pediatric tertiary care hospital. J Patient Saf. 2023;19(4):251-257. doi:10.1097/pts.0000000000001…
-
psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - healthcare team huddles to discuss patient issues and family concerns, observations of rounds to ensure proper
-
psnet.ahrq.gov/web-mm/hazards-loading-doses
December 01, 2003 - calculate patient-specific loading doses.( 8 ) Since transitions of care are prone to medication errors, proper … Unusual dosing should always be questioned and verified directly with the initiating service; proper
-
psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
July 02, 2019 - A well-designed order set would support selection of proper bolus dosing, correct rate of maintenance … decision support, the order set should have been designed to provide guidance as to how to select the proper
-
psnet.ahrq.gov/node/49468/psn-pdf
December 16, 2004 - Per the Universal Protocol, the
surgeon marked the proper leg prior to bringing the patient to the OR
-
psnet.ahrq.gov/innovation/critical-radiology-alert-process
November 16, 2022 - network with the innovating organization, 3) completing the ED follow-up request form, and 4) making a proper … nurse case managers and cancer center navigators to ensure all patients with critical alerts receive proper
-
psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
April 28, 2021 - A feel for how much force should be applied during trocar insertion, the proper angle, controlling thrust … A Demonstration of Proper Technique for Trocar Insertion* (Illustration by Chris Gralapp)
-
psnet.ahrq.gov/issue/utilising-improvement-science-methods-optimise-medication-reconciliation
July 24, 2017 - 5, 2011
Utilizing improvement science methods to improve physician compliance with proper
-
psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
February 01, 2004 - contact patients about abnormal test results that is proportionate to the harm that might occur without proper
-
psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
March 01, 2009 - 1-3 ) This finding is not surprising, as patients often lack sufficient information to help support proper … Clinicians should ensure patients are adequately counseled regarding the proper use of a medication and … should be written and transmitted to a pharmacy in a manner that does not allow for deviation from proper
-
psnet.ahrq.gov/node/36927/psn-pdf
April 14, 2011 - The frequency of missed test results and associated
treatment delays in a highly computerized health system.
April 14, 2011
Wahls TL, Cram PM. The frequency of missed test results and associated treatment delays in a highly
computerized health system. BMC Fam Pract. 2007;8:32.
https://psnet.ahrq.gov/issue/frequenc…
-
psnet.ahrq.gov/node/36907/psn-pdf
September 14, 2012 - Serious Reportable Events in Healthcare—2011 Update.
September 14, 2012
Washington DC: National Quality Forum; December 2011.
https://psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update
The National Quality Forum originally defined 27 health care "never events"—patient safety events that
pose ser…
-
psnet.ahrq.gov/web-mm/urine-tough-position
January 01, 2009 - Therefore, verification of patient identification and proper labeling of specimens, requisitions, and … Then, clinical staff can collaborate to design fail-safe mechanisms for ensuring proper specimen identification
-
psnet.ahrq.gov/node/49389/psn-pdf
February 01, 2003 - A feel for how much force should be applied during trocar insertion, the
proper angle, controlling thrust … A Demonstration of Proper Technique for Trocar Insertion* (Illustration by Chris Gralapp)
http://www.ncbi.nlm.nih.gov
-
psnet.ahrq.gov/node/49745/psn-pdf
October 01, 2015 - Had she received the proper medication at the proper dose during her admission, she
may have not needed
-
psnet.ahrq.gov/node/37417/psn-pdf
March 28, 2012 - Medication use leading to emergency department visits
for adverse drug events in older adults.
March 28, 2012
Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for
adverse drug events in older adults. Ann Intern Med. 2007;147(11):755-765.
https://psnet.ahrq.gov/issue/med…
-
psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - feedback, that is guided by mutual trust and respect. 10 The last “hole” in this case was the lack of proper … review the prescription against the data, confirm the correct patient, appropriate medication, and proper
-
psnet.ahrq.gov/node/866841/psn-pdf
September 23, 2024 - Shaheen says that proper EHR integration could allow smaller organizations to implement this
innovation
-
psnet.ahrq.gov/web-mm/little-shuteye
December 22, 2018 - This was the physician’s first experience using this agent, and there had been no training on its proper … Proper use of tissue adhesives involves choosing appropriate wounds, as well as patients, for the procedure