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psnet.ahrq.gov/issue/improving-patient-safety-culture-practical-guide
April 23, 2014 - April 23, 2014
Review into the Quality of Care and Treatment Provided by 14 Hospital
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psnet.ahrq.gov/issue/future-nhs-patient-safety-investigation
April 18, 2018 - August 2, 2023
Review into the Quality of Care and Treatment Provided by 14 Hospital
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psnet.ahrq.gov/issue/learning-use-patient-stories
July 18, 2018 - February 2, 2022
Review into the Quality of Care and Treatment Provided by 14 Hospital
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psnet.ahrq.gov/node/42063/psn-pdf
January 06, 2018 - were somewhat
controversial, the report galvanized patient safety efforts at hospitals nationwide and provided
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psnet.ahrq.gov/issue/medical-errors-leave-devastating-impact-families-professionals
August 11, 2010 - November 12, 2014
Review into the Quality of Care and Treatment Provided by 14 Hospital
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psnet.ahrq.gov/issue/drug-errors-show-need-tech-aid
August 17, 2016 - May 27, 2011
Reasons provided by prescribers when overriding drug–drug interaction alerts
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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - These risks are traded off against the potential benefits of the additional care provided by ICU nurses … The SBAR example is based upon the worksheet tool provided by the Institute for Healthcare Improvement … Assigning patients to nurses who provided care to them recently. … It could be argued that the heuristics provided here do not directly address all of the issues raised
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psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - In teaching hospitals, radiology residents have traditionally provided preliminary interpretations during … in the emergency department and on inpatient wards.(1) In most cases, the only off-
hours services provided … having full-time coverage by academic radiologists does not
currently seem feasible and teleradiology provided … by general radiologists may be inferior to that provided
by subspecialty radiologists, perhaps “higher-risk
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psnet.ahrq.gov/issue/just-culture-guide
July 18, 2018 - August 2, 2023
Review into the Quality of Care and Treatment Provided by 14 Hospital
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psnet.ahrq.gov/issue/variation-patient-safety-outcomes-and-importance-being-informed
July 02, 2014 - February 12, 2014
Review into the Quality of Care and Treatment Provided by 14 Hospital
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psnet.ahrq.gov/issue/lessons-americas-safest-hospitals
November 16, 2016 - November 12, 2014
Review into the Quality of Care and Treatment Provided by 14 Hospital
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psnet.ahrq.gov/issue/examining-medication-reconciliation-perspective-safety
August 11, 2010 - August 19, 2020
Review into the Quality of Care and Treatment Provided by 14 Hospital
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psnet.ahrq.gov/perspective/acgmes-2017-revision-common-program-requirements
January 31, 2018 - Graduate Medical Education (ACGME) is committed to supporting the safety and quality of patient care provided … responded.( 2 ) The ACGME also invited input from the community, and 61 individuals and organizations provided … education and professional development.( 10,14,15 )
To further investigate these issues, the ACGME provided
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psnet.ahrq.gov/node/33711/psn-pdf
May 01, 2011 - Incredibly, many of the research participants provided meticulously detailed accounts
of their respective … Some were able to cite the exact date of the event while others provided event-
specific details such … Research participants provided many insights into the complex second victim phenomenon.
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psnet.ahrq.gov/node/49775/psn-pdf
November 01, 2016 - for transitioning the paper orders to CPOE did not realize that the
old paper electrolyte order set provided … 3,11) Clinician involvement could have been helpful in this case to recognize
the decision support provided … Ultimately, the failure to recognize
and maintain decision support that had been provided in the paper
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psnet.ahrq.gov/node/49688/psn-pdf
August 21, 2013 - surgeon due to the effects of anesthesia (no written instructions on the updated recovery plan were
provided … effects; multiple activities at one time, such as electrocardiogram being done when information
is provided … information about a medical
condition and its management.(11,12) In this case, the surgery team could have provided
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - systems-based approach grounded in a culture of safety to ensure that the
highest value care is reliably provided … hospitalist
services have agreed that the ED physician will be responsible for ensuring appropriate care is provided … volume can lead to delays in safe transitions from the ED to a setting
where definitive therapy can be provided
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psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
March 01, 2015 - Instead, the nurse answering the radio should have acted on the information provided by EMS personnel … to a verbal report from EMS providers, the minimum key information required for patient care must be provided … These changes likely represent a response to treatment provided by EMS, such as rest, oxygen, aspirin
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psnet.ahrq.gov/node/33629/psn-pdf
March 01, 2006 - box
https://psnet.ahrq.gov//#ref5
https://psnet.ahrq.gov//#ref6
Generic training on teamwork can be provided … should be built into training
Complex simulation scenarios provide this opportunity; guidance
is provided … strategy
Timely feedback is critical to allow team
members to adjust their knowledge
Feedback is provided
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - A recently published report showed that medication identification services can be effectively provided … note documented in an electronic medical record that is viewed across all patient encounters may have provided … These cases may be justified to avoid any delay or problem with therapy—provided that all of the safeguards