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5921. Cultural Competence and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
      December 27, 2019 - Cultural Competence and Patient Safety December 27, 2019  Also Read the Conversation View more articles from the same authors. Citation Text: Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthc…

5922. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35952/psn-pdf
      August 02, 2010 - Manage staff fatigue to improve patient safety. August 2, 2010 Spath P. Manage staff fatigue to improve patient safety. Part 2 of 2. Hospital peer review. 2006;31(5):70-2. https://psnet.ahrq.gov/issue/manage-staff-fatigue-improve-patient-safety The author discusses three steps for reducing staff fatigue. Part I of …

5923. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42596/psn-pdf
      October 23, 2013 - Diagnostic Errors and Strategies to Minimize Them. October 23, 2013 Cutrer WB, Sullivan WM, Fleming AE, et al. Curr Probl Pediatr Adolesc Health Care. 2013;43:225-257.   https://psnet.ahrq.gov/issue/diagnostic-errors-and-strategies-minimize-them Articles in this special issue cover diagnostic errors, includin…

5924. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38992/psn-pdf
      April 16, 2018 - Safe patient outcomes occur with timely, standardized communication of critical values. April 16, 2018 https://psnet.ahrq.gov/issue/safe-patient-outcomes-occur-timely-standardized-communication-critical- values This article reports on failures surrounding critical test results and describes mechanisms to standardi…

5925. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36533/psn-pdf
      May 27, 2011 - Effect of computerisation on the quality and safety of chemotherapy prescription. May 27, 2011 Voeffray M, Pannatier A, Stupp R, et al. Effect of computerisation on the quality and safety of chemotherapy prescription. Qual Saf Health Care. 2006;15(6):418-21. https://psnet.ahrq.gov/issue/effect-computerisation-qual…

5926. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34002/psn-pdf
      March 17, 2011 - Utah DoH Patient Safety Initiatives. March 17, 2011 Center for Health Data, Utah Department of Health, PO Box 144004, Salt Lake City, UT 84114. https://psnet.ahrq.gov/issue/utah-doh-patient-safety-initiatives Utah established a number of collaborative initiatives to understand the nature and occurrence of adverse …

5927. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41562/psn-pdf
      August 01, 2012 - The Final Check: Say it Out Loud. August 1, 2012 https://psnet.ahrq.gov/issue/final-check-say-it-out-loud This Web site provides resources to help reduce incidence of mislabeled blood specimens based on just culture concepts. https://psnet.ahrq.gov/issue/final-check-say-it-out-loud https://psnet.ahrq.gov/web-mm/ri…

5928. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50601/psn-pdf
      October 09, 2022 - Medication Safety: Advancing the Development of Improvement Strategies and Tools (R18). October 9, 2022  Rockville, MD: Agency for Healthcare Research and Quality; September 28, 2022. PA- 20-028. https://psnet.ahrq.gov/issue/medication-safety-advancing-development-improvement Medication errors are …

5929. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41447/psn-pdf
      May 30, 2012 - Massachusetts hospitals launch patient apology program. May 30, 2012 Gallegos A. https://psnet.ahrq.gov/issue/massachusetts-hospitals-launch-patient-apology-program This news article reports on a disclosure and apology program implemented in Massachusetts hospitals to reduce liability lawsuits. https://psnet.ahrq…

5930. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39484/psn-pdf
      April 28, 2010 - Surgical fires, a clear and present danger. April 28, 2010 Yardley IE, Donaldson LJ. Surgical fires, a clear and present danger. Surgeon. 2010;8(2):87-92. doi:10.1016/j.surge.2010.01.005. https://psnet.ahrq.gov/issue/surgical-fires-clear-and-present-danger This article reviews the literature on surgical fires and …

5931. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35891/psn-pdf
      May 03, 2006 - Costs and Benefits of Health Information Technology. May 3, 2006 Shekelle PG, Morton SC, Keeler EB. Rockville, MD: Agency for Healthcare Research and Quality; April 2006. AHRQ Publication No. 06-E006. https://psnet.ahrq.gov/issue/costs-and-benefits-health-information-technology The authors reviewed the literature …

5932. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50584/psn-pdf
      October 23, 2019 - Unprotected: broken promises in Georgia’s senior care industry. October 23, 2019 Schrade B, Teegardin C. Atlanta Journal-Constitution. Sept-October 2019. https://psnet.ahrq.gov/issue/unprotected-broken-promises-georgias-senior-care-industry Assisted living facilities have challenges that reduce the quality and saf…

5933. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38709/psn-pdf
      June 17, 2009 - Enteral feeding misconnections: an update. June 17, 2009 Guenter P, Hicks RW, Simmons D. Enteral feeding misconnections: an update. Nutr Clin Pract. 2009;24(3):325-34. doi:10.1177/0884533609335174. https://psnet.ahrq.gov/issue/enteral-feeding-misconnections-update This review surveys information on enteral nutriti…

5934. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40553/psn-pdf
      June 22, 2011 - Applying the Universal Protocol to improve patient safety in radiology services. June 22, 2011 PA-PSRS Patient Saf Advis. June 2011;8:63-69. https://psnet.ahrq.gov/issue/applying-universal-protocol-improve-patient-safety-radiology-services Exploring causes of wrong-site, wrong patient, and wrong procedure errors i…

5935. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39255/psn-pdf
      February 02, 2011 - The patient who falls: "It's always a trade-off." February 2, 2011 Tinetti ME, Kumar C. The patient who falls: "It's always a trade-off". JAMA. 2010;303(3):258-66. doi:10.1001/jama.2009.2024. https://psnet.ahrq.gov/issue/patient-who-falls-its-always-trade Through a case study, this article reviews evidence on risk…

5936. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41636/psn-pdf
      August 29, 2012 - Far more could be done to stop the deadly bacteria C. diff. August 29, 2012 Eisler P. USA Today. August 16, 2012. https://psnet.ahrq.gov/issue/far-more-could-be-done-stop-deadly-bacteria-c-diff This newspaper article reports on how clinicians, hospitals, and health care systems can reduce incidence of hospital-acq…

5937. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34925/psn-pdf
      February 27, 2009 - Medication errors and professional practice of registered nurses. February 27, 2009 Deans C. Medication errors and professional practice of registered nurses. Collegian. 2005;12(1):29-33. https://psnet.ahrq.gov/issue/medication-errors-and-professional-practice-registered-nurses This Australian study identified and…

5938. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60216/psn-pdf
      April 08, 2020 - The Diagnosis of Ectopic Pregnancy. April 8, 2020 Farnborough, UK:  Healthcare Safety Investigation Branch; March 2020. https://psnet.ahrq.gov/issue/diagnosis-ectopic-pregnancy Missed or delayed diagnosis in maternal care can result in serious harm to both the mother and the child. This report analyzes a dela…

5939. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36798/psn-pdf
      March 09, 2009 - Organizational culture, critical success factors, and the reduction of hospital errors. March 9, 2009 Stock GN, McFadden KL, Gowen CR. Organizational culture, critical success factors, and the reduction of hospital errors. Int J Prod Econ. 2006;106(2). doi:10.1016/j.ijpe.2006.07.005. https://psnet.ahrq.gov/issue/o…

5940. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40937/psn-pdf
      November 16, 2011 - AHRQ Projects to Prevent Healthcare-Associated Infections, Fiscal Year 2011. November 16, 2011 Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 09- P013-4-E. https://psnet.ahrq.gov/issue/ahrq-projects-prevent-healthcare-associated-infections-fiscal-year-2011 This annou…