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Showing results for "reducing".

7561. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44939/psn-pdf
      March 09, 2016 - Listening for What Matters: Avoiding Contextual Errors in Health Care. March 9, 2016 Weiner SJ, Schwartz A. New York, NY: Oxford University Press; 2016. ISBN: 9780190228996. https://psnet.ahrq.gov/issue/listening-what-matters-avoiding-contextual-errors-health-care This book discusses how physicians can reduce cont…

7562. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39552/psn-pdf
      May 26, 2010 - Expanding what we know about off-peak mortality in hospitals. May 26, 2010 Hamilton P, Mathur S, Gemeinhardt G, et al. Expanding what we know about off-peak mortality in hospitals. J Nurs Adm. 2010;40(3):124-8. doi:10.1097/NNA.0b013e3181d0426e. https://psnet.ahrq.gov/issue/expanding-what-we-know-about-peak-mortali…

7563. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43912/psn-pdf
      February 25, 2015 - Patient Safety in Dialysis Access. February 25, 2015 Widmer MK, Malik J, eds. Contrib Nephrol. 2015;184:1-270. ISBN: 9783318027051. https://psnet.ahrq.gov/issue/patient-safety-dialysis-access Patients with chronic kidney failure are at high risk for adverse events from treatment errors. This publication raises awa…

7564. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46800/psn-pdf
      May 16, 2018 - Ireland investigates cervical cancer screening scandal. May 16, 2018 O'Loughlin E. New York Times. April 30, 2018. https://psnet.ahrq.gov/issue/ireland-investigates-cervical-cancer-screening-scandal Large-scale adverse events should lead to system examination and improvement. This newspaper article reports on misr…

7565. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/864386/psn-pdf
      March 13, 2024 - Time for prefilled syringes - everywhere. March 13, 2024 Whitaker DK, Lomas JP. Time for prefilled syringes – everywhere. Anaesthesia. 2024;79(2):119-122. doi:10.1111/anae.16181. https://psnet.ahrq.gov/issue/time-prefilled-syringes-everywhere Simplifying complex processes is a strategy to engineer safety into heal…

7566. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46477/psn-pdf
      January 08, 2018 - The iatrogenic potential of the physician's words. January 8, 2018 Barsky AJ. The Iatrogenic Potential of the Physician's Words. JAMA. 2017;318(24):2425-2426. doi:10.1001/jama.2017.16216. https://psnet.ahrq.gov/issue/iatrogenic-potential-physicians-words Inadequate information sharing between physicians and patien…

7567. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38503/psn-pdf
      June 16, 2009 - Antimicrobial prescription errors in hospitalized children: role of antimicrobial stewardship program in detection and intervention. June 16, 2009 Di Pentima C, Chan S, Eppes SC, et al. Antimicrobial prescription errors in hospitalized children: role of antimicrobial stewardship program in detection and interventi…

7568. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40160/psn-pdf
      January 19, 2011 - Morphine sulfate oral solution 100 mg per 5 mL (20 mg/mL): medication use error—reports of accidental overdose. January 19, 2011 MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 10, 2011. https://psnet.ahrq.gov/issue/morphine-sulfate-oral-solution-100-mg-5-ml-20-mgml-medication-us…

7569. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38686/psn-pdf
      May 07, 2018 - Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups? May 7, 2018 ISMP Medication Safety Alert! Acute Care Edition. May 21, 2009;14:1-3. https://psnet.ahrq.gov/issue/survey-lasa-drug-name-pairs-who-knows-whats-your-list-and-best-ways- prevent-mix-ups This article shar…

7570. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/764408/psn-pdf
      March 02, 2022 - Ensuring critical instruments and devices are appropriate for reuse. March 2, 2022 Quick Safety. February 14, 2022;(64):1-3. https://psnet.ahrq.gov/issue/ensuring-critical-instruments-and-devices-are-appropriate-reuse Complete, appropriate reprocessing and sterilization of reusable medical instruments and devices …

7571. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43183/psn-pdf
      May 14, 2014 - Physician: 'I almost killed a patient' because of an advance directive. May 14, 2014 Betbeze P. HealthLeaders Media. May 2, 2014. https://psnet.ahrq.gov/issue/physician-i-almost-killed-patient-because-advance-directive Reporting on how misinterpretation of advance directives and living wills can detract from patie…

7572. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41410/psn-pdf
      May 23, 2012 - The World Health Organization '5 moments of hand hygiene': the scientific foundation. May 23, 2012 Chou DTS, Achan P, Ramachandran M. The World Health Organization '5 moments of hand hygiene': the scientific foundation. J Bone Joint Surg Br. 2012;94(4):441-5. doi:10.1302/0301-620X.94B4.27772. https://psnet.ahrq.go…

7573. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44296/psn-pdf
      April 08, 2018 - Checklists to prevent diagnostic errors: a pilot randomized controlled trial. April 8, 2018 Ely JW, Graber MA. Checklists to prevent diagnostic errors: a pilot randomized controlled trial. Diagnosis (Berl). 2015;2(3):163-169. doi:10.1515/dx-2015-0008. https://psnet.ahrq.gov/issue/checklists-prevent-diagnostic-erro…

7574. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44143/psn-pdf
      April 15, 2016 - "First, know thyself": cognition and error in medicine. April 15, 2016 Elia F, Aprà F, Verhovez A, et al. "First, know thyself": cognition and error in medicine. Acta Diabetol. 2016;53(2):169-175. doi:10.1007/s00592-015-0762-8. https://psnet.ahrq.gov/issue/first-know-thyself-cognition-and-error-medicine Cognition …

7575. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45334/psn-pdf
      September 07, 2016 - Why 'Universal Precautions' are needed for medication lists. September 7, 2016 Shane R. Why 'Universal Precautions' are needed for medication lists. BMJ Qual Saf. 2016;25(9):731-2. doi:10.1136/bmjqs-2015-005116. https://psnet.ahrq.gov/issue/why-universal-precautions-are-needed-medication-lists Despite the support…

7576. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44602/psn-pdf
      November 25, 2015 - Interorganizational complexity and organizational accident risk: a literature review. November 25, 2015 Milch V, Laumann K. Interorganizational complexity and organizational accident risk: A literature review. Safety Sci. 2015;82:9-17. doi:10.1016/j.ssci.2015.08.010. https://psnet.ahrq.gov/issue/interorganizationa…

7577. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46593/psn-pdf
      November 08, 2017 - Unreadable barcodes and multiple barcodes on packages can lead to errors. November 8, 2017 ISMP Medication Safety Alert! Acute care edition. October 19, 2017;22:1-3. https://psnet.ahrq.gov/issue/unreadable-barcodes-and-multiple-barcodes-packages-can-lead-errors Barcodes can both enhance and degrade the medication …

7578. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43415/psn-pdf
      September 10, 2014 - Project BOOST implementation: lessons learned. September 10, 2014 Williams M, Li J, Hansen LO, et al. Project BOOST implementation: lessons learned. South Med J. 2014;107(7):455-65. doi:10.14423/SMJ.0000000000000140. https://psnet.ahrq.gov/issue/project-boost-implementation-lessons-learned This qualitative study o…

7579. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41510/psn-pdf
      July 11, 2012 - Dangerous connections: health care community tackles tubing risks, small-bore connector standards. July 11, 2012 Vockley M. Joint Commission: The Source. June 2012;10:15-17. https://psnet.ahrq.gov/issue/dangerous-connections-health-care-community-tackles-tubing-risks-small- bore-connector This newsletter article …

7580. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73101/psn-pdf
      April 07, 2021 - Do No Harm: Are We Preventing Medication Errors in Children with Medical Complexity? March 31, 2021 Children's Healthcare Canada. April 7, 2021. https://psnet.ahrq.gov/issue/do-no-harm-are-we-preventing-medication-errors-children-medical-complexity Children are particularly vulnerable to medication errors. This se…