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5441. Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room. | PSNet
      psnet.ahrq.gov/issue/minor-flow-disruptions-traffic-related-factors-and-their-effect-major-flow-disruptions
      August 19, 2020 - Study Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room. Citation Text: Joseph A, Khoshkenar A, Taaffe KM, et al. Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating roo…

5442. The perfect storm: exam of a medical error and factors contributing to its possible escalation. | PSNet
      psnet.ahrq.gov/issue/perfect-storm-exam-medical-error-and-factors-contributing-its-possible-escalation
      October 20, 2021 - Commentary The perfect storm: exam of a medical error and factors contributing to its possible escalation. Citation Text: Walters GK. The perfect storm: exam of a medical error and factors contributing to its possible escalation. J Patient Saf. 2021;17(4):e264-e267. doi:10.1097/pts.00000…

5443. The burden of healthcare utilization, cost, and mortality associated with select surgical site infections. | PSNet
      psnet.ahrq.gov/issue/burden-healthcare-utilization-cost-and-mortality-associated-select-surgical-site-infections
      October 09, 2024 - Study The burden of healthcare utilization, cost, and mortality associated with select surgical site infections. Citation Text: Shambhu S, Gordon AS, Liu Y, et al. The burden of healthcare utilization, cost, and mortality associated with select surgical site infections. Jt Comm J Qual Pa…

5444. Communication failure: analysis of prescribers' use of an internal free-text field on electronic prescriptions. | PSNet
      psnet.ahrq.gov/issue/communication-failure-analysis-prescribers-use-internal-free-text-field-electronic
      May 20, 2019 - Study Communication failure: analysis of prescribers' use of an internal free-text field on electronic prescriptions. Citation Text: Ai A, Wong A, Amato MG, et al. Communication failure: analysis of prescribers’ use of an internal free-text field on electronic prescriptions. J Am Med Inf…

5445. Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals. | PSNet
      psnet.ahrq.gov/issue/universal-surveillance-methicillin-resistant-staphylococcus-aureus-3-affiliated-hospitals
      December 23, 2008 - Study Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals. Citation Text: Robicsek A, Beaumont JL, Paule SM, et al. Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals. Ann Intern Med. 2008;148(6)…

5446. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38845/psn-pdf
      August 05, 2009 - Hospitals tally their avoidable mistakes. August 5, 2009 Rein L. Washington Post. July 21, 2009:E1. https://psnet.ahrq.gov/issue/hospitals-tally-their-avoidable-mistakes This news article reports on Washington, DC–area initiatives to track preventable patient injury and discusses strategies to hold hospitals accou…

5447. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42478/psn-pdf
      August 07, 2013 - A guide for HCAs on safe patient transfers. August 7, 2013 Lees L. https://psnet.ahrq.gov/issue/guide-hcas-safe-patient-transfers This commentary offers practical advice for health care assistants to reduce risks during patient transfers. https://psnet.ahrq.gov/issue/guide-hcas-safe-patient-transfers https://psnet…

5448. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37282/psn-pdf
      September 27, 2016 - Verbal medication orders in the OR. September 27, 2016 Hendrickson T. Verbal medication orders in the OR. AORN J. 2007;86(4):626-9. https://psnet.ahrq.gov/issue/verbal-medication-orders-or This article describes the causes of medication errors in the operating room and discusses prevention strategies, including us…

5449. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37305/psn-pdf
      January 02, 2011 - Medication administration in anesthesia: time for a paradigm shift. January 2, 2011 Stabile M; Webster CS; Merry AF. https://psnet.ahrq.gov/issue/medication-administration-anesthesia-time-paradigm-shift To reduce anesthesia administration errors, the authors propose changing the organizational culture to foster a…

5450. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34905/psn-pdf
      February 25, 2009 - On the quest for Six Sigma. February 25, 2009 Moorman D. On the quest for Six Sigma. Am J Surg. 2005;189(3):253-8. https://psnet.ahrq.gov/issue/quest-six-sigma This discussion of patient safety from a surgical perspective highlights issues involving hierarchy, human factors, and multidisciplinary team training as …

5451. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40497/psn-pdf
      June 15, 2011 - Are we finally getting serious about medical errors? June 15, 2011 Burns J. https://psnet.ahrq.gov/issue/are-we-finally-getting-serious-about-medical-errors This article explores the challenges to improving patient safety and discusses strategies for reducing medical errors. https://psnet.ahrq.gov/issue/are-we-fi…

5452. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40299/psn-pdf
      April 16, 2018 - Medication errors in the emergency department: need for pharmacy involvement? April 16, 2018 https://psnet.ahrq.gov/issue/medication-errors-emergency-department-need-pharmacy-involvement This piece reports on the prevalence of medication errors in the emergency department and suggests expanding pharmacy involvemen…

5453. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety | PSNet
      psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
      March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety Sara J. Singer, MBA, PhD | September 1, 2013  View more articles from the same authors. Citation Text: Singer SJ. What We've Learned About Leveraging Leadership a…

5454. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49812/psn-pdf
      November 01, 2017 - Specimen Almost Lost November 1, 2017 Hehe YK. Specimen Almost Lost. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/specimen-almost-lost The Case A 29-year-old woman presented to the hospital with a rash that had spread across her legs and abdomen. She was admitted to the medicine service for further evalu…

5455. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49532/psn-pdf
      March 15, 2007 - Back to Basics March 1, 2007 Hellman R. Back to Basics. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/back-basics The Case A 48-year-old woman with insulin-dependent diabetes mellitus presents to the emergency department with right upper quadrant pain, fever, and leukocytosis, prompting admission for pres…

5456. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.173_slideshow.ppt
      April 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case April 2008 Antibiotics for URI/Sinusitis: A Simple Decision Gone Bad Source and Credits This presentation is based on the April 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Sumant Ranji, MD,…

5457. Critical Radiology Alert Process | PSNet
      psnet.ahrq.gov/innovation/critical-radiology-alert-process
      November 16, 2022 - Critical Radiology Alert Process Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL October 30, 2024 View more articles from the same authors. Innovation Contact …

5458. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
      November 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case November 2006 Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Source and Credits This presentation is based on the November 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is…

5459. Advancement toward High Reliability in Healthcare Awards. | PSNet
      psnet.ahrq.gov/issue/advancement-toward-high-reliability-healthcare-awards
      June 08, 2011 - January 21, 2009 Teamwork is associated with reduced hospital staff burnout at military

5460. Fatal drug mix-up exposes hospital flaws. | PSNet
      psnet.ahrq.gov/issue/fatal-drug-mix-exposes-hospital-flaws
      March 02, 2016 - July 10, 2018 Teamwork is associated with reduced hospital staff burnout at military