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January 01, 2009 - Accordingly, policies may be very
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https://psnet.ahrq.gov//#references … Changing EMS Policy
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This is … References
1. Pham JC, Patel R, Millin MG, Kirsch TD, Chanmugam A. … [go to PubMed]
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http://www.ncbi.nlm.nih.gov/pubmed/16946281
http:
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November 01, 2008 - https://psnet.ahrq.gov/web-mm/mid-summer-fog
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This case clearly … https://psnet.ahrq.gov/issue/national-surgical-quality-improvement-program
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Basic principles of adult learning suggest that content-heavy … https://psnet.ahrq.gov//#references
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Finally, the variety of approaches that hospitals take to improve
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July 12, 2004 - https://psnet.ahrq.gov//#references
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Errors during cross-coverage are … Clinical Professor Assistant Chief of the Medical Service University of
California, San Francisco
References
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psnet.ahrq.gov/node/49616/psn-pdf
December 01, 2010 - colleagues reported that the most common errors in the medication use process in
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children occurred during physician prescribing (74%) and nurse … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#table
https://psnet.ahrq.gov//#references … Francisco
Tessa Dixon, PharmD Pharmacy Resident, Lucile Packard Children's Hospital at Stanford
References
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psnet.ahrq.gov/node/49790/psn-pdf
April 01, 2017 - https://psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
https://psnet.ahrq.gov//#references … If an
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electronic health record allows coded entries differentiating … Doyle, MBBS GP Principal Indigo Medical Jersey, Channel Islands
References
1.
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March 01, 2006 - https://psnet.ahrq.gov//#box
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https://psnet.ahrq.gov//#references … If the resident finds an
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https … ://psnet.ahrq.gov//#references
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https: … References
1. Hunter TB, Krupinski EA, Hunt KR, Erly WK.
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July 01, 2008 - tendency to cast blame and
https://psnet.ahrq.gov/web-mm/wrong-route-nutrients
https://psnet.ahrq.gov//#references … it can be argued that the LPN was not attempting to be reckless with her
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https://psnet.ahrq.gov//#references … Scott-Cawiezell, RN, PhD Associate Professor University of Missouri-Columbia, Sinclair School of
Nursing
References … [go to PubMed]
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http://www.ncbi.nlm.nih.gov/pubmed/15636418
http:
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May 01, 2012 - float services when residents care for patients for whom they lack primary knowledge
See Notes for references … of attending physicians and residents currently responsible for each patient’s care
See Notes for references … that these techniques improve clinical practice; unclear impact on patient outcomes
See Notes for references … feedback from trained ‘receiver’
Practice-based audit tools to improve
written sign-out
See Notes for references … synopsis, relevant action items, anticipatory guidance with corresponding rationale
See Notes for references
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psnet.ahrq.gov/node/49514/psn-pdf
July 01, 2006 - information from the patient, any
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https://psnet.ahrq.gov//#references … (RALES), only 1.7% of heart failure patients treated with spironolactone
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
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https://psnet.ahrq.gov//#references … Departments of
Medicine, Pediatrics, and Health Policy, Management, and Evaluation University of Toronto
References … [go to PubMed]
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http://www.ncbi.nlm.nih.gov
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October 01, 2012 - Unfortunately, there are limits to medication-safety
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engineering. … Manias, PhD, RN, MPharm Professor Melbourne School of Health Sciences The University of
Melbourne
References … name=anchoringerror
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http://www.ncbi.nlm.nih.gov/pubmed/18238771
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September 01, 2006 - these differences in
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both approach to and outcomes of life-sustaining interventions … these issues with patients or surrogates and be guided by their informed
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preferences and choices.(6 … [go to PubMed]
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psnet.ahrq.gov/node/49692/psn-pdf
September 01, 2013 - workarounds might be considered comparable to a "near miss," that is, an
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opportunity to recognize a dysfunction in the existing system. … Awareness Officer, Veterans Health Administration
Director, VA National Center for Patient Safety
References … [go to PubMed]
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http://www.ncbi.nlm.nih.gov/pubmed/12091660
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August 01, 2012 - Up to 25% of these lawsuits are from avoidable failures in the test follow-up system
See Notes for references … few times a year, they have seen a patient worsen due to delays in lab test follow-up
See Notes for references … lists
Forwarding capability and allowing the use of surrogates during planned absences
See Notes for references … handoff procedures to manage results during times of provider absence (i.e., weekends)
See Notes for references … due to "fatigue" on the part of the clinicians (too many alerts become overwhelming)
18
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April 01, 2009 - implementation and usability difficulties, which I will review below.(2,3)
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Potential Challenges with … While these
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house officers uniformly … https://psnet.ahrq.gov//#references
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Although the present case was
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December 01, 2007 - web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
https://psnet.ahrq.gov//#references … "(8) In absolute terms, however, the
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rate of quality problems was
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September 01, 2008 - point to
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support a search is that there … https://psnet.ahrq.gov//#references
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compare targeted treatment … https://psnet.ahrq.gov//#references
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While awaiting other tests, … References
1. Mikami K, Suzuki M, Kitagawa H, et al.
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November 01, 2010 - days of discharge from the hospital
9%-48% of hospital re-admissions are preventable
See Notes for references … follow-up visit
Post-discharge, patients often have heightened needs for timely care
See Notes for references … treatment
Account for 25% of diagnosis-related malpractice law suits from one insurer
*
See Notes for references … with high patient safety awareness in general
Presence of electronic medical record
*
See Notes for references … telephone calls, scheduling appointments for patients within 1 week of discharge)
*
See Notes for references
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psnet.ahrq.gov/node/49685/psn-pdf
May 01, 2013 - https://psnet.ahrq.gov//#references
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https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
Using multiple pharmacies (unless it involves a chain with an … Dean, School of Pharmacy Professor of Clinical Pharmacy University of
California, San Francisco
References
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psnet.ahrq.gov/node/49495/psn-pdf
December 01, 2005 - received an invasive cardiac procedure intended for another
patient.(5)
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https://psnet.ahrq.gov//#references … References
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1. Sexton J, Helmreich R, Thomas E. … cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12679507
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psnet.ahrq.gov/node/49824/psn-pdf
March 01, 2018 - means that personnel must respond, set up the laboratory, receive and prepare
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Emergency department personnel … Chair Department of Emergency Medicine University of
Virginia School of Medicine Charlottesville, VA
References