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psnet.ahrq.gov/issue/culture-safety-ems-systems-0
February 18, 2011 - Organizational Policy/Guidelines
A culture of safety in EMS systems.
Citation Text:
A culture of safety in EMS systems. American College of Emergency Physicians, National Association of Emergency Medical Services. Ann Emerg Med. 2021;78(3):e37-e57.
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psnet.ahrq.gov/issue/high-reliability-and-i-pass-communication-tool
June 02, 2021 - Newspaper/Magazine Article
High-reliability and the I-PASS communication tool.
Citation Text:
Clements K. High-reliability and the I-PASS communication tool. Nursing Management (Springhouse). 2017;48(3). doi:10.1097/01.numa.0000512897.68425.e5.
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psnet.ahrq.gov/issue/nearing-zeroreducing-grade-c-medication-errors
October 05, 2022 - Commentary
Nearing zero...reducing grade C medication errors.
Citation Text:
Cockerham J, Figueroa-Altmann A, Foxen C, et al. Nearing zero..reducing grade C medication errors. Nurs Manage. 2014;45(7):26-31. doi:10.1097/01.NUMA.0000451033.38845.d3.
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DOI …
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psnet.ahrq.gov/issue/three-perspectives-changes-resident-work-environment-and-duty-hours
September 02, 2020 - Commentary
Three perspectives on changes in resident work environment and duty hours.
Citation Text:
Three perspectives on changes in resident work environment and duty hours. Bilimoria KY, Meyers MO, Mouawad NJ, et al. JAMA Surg. 2017;152(10):903-908.
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psnet.ahrq.gov/issue/potentially-fatal-errors-gdh-pqq-glucose-dehydrogenase-pyrroloquinoline-quinone-glucose
June 22, 2011 - Press Release/Announcement
Potentially fatal errors with GDH-PQQ [glucose dehydrogenase pyrroloquinoline quinone] glucose monitoring technology.
Citation Text:
Potentially fatal errors with GDH-PQQ [glucose dehydrogenase pyrroloquinoline quinone] glucose monitoring technology. MedWat…
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psnet.ahrq.gov/issue/investigating-improvement-five-strategies-ensure-national-patient-safety-investigations
February 28, 2024 - Commentary
Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety.
Citation Text:
Macrae C. Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety. J R Soc Med.…
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psnet.ahrq.gov/issue/designing-safer-process-prevent-retained-surgical-sponges-healthcare-failure-mode-and-effect
April 27, 2019 - Study
Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis.
Citation Text:
Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94(2):1…
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psnet.ahrq.gov/issue/quality-improvement-and-patient-safety-activities-academic-departments-medicine
July 02, 2014 - Study
Quality improvement and patient safety activities in academic departments of medicine.
Citation Text:
Neeman N, Sehgal NL, Davis RB, et al. Quality improvement and patient safety activities in academic departments of medicine. Am J Med. 2012;125(8):831-5. doi:10.1016/j.amjmed.201…
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psnet.ahrq.gov/issue/hipaa-and-patient-care-role-professional-judgment
June 22, 2022 - Commentary
HIPAA and patient care: the role for professional judgment.
Citation Text:
Lo B, Dornbrand L, Dubler NN. HIPAA and patient care: the role for professional judgment. JAMA. 2005;293(14):1766-71.
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psnet.ahrq.gov/issue/cms-proposal-suppress-hospital-safety-data-angers-advocates-agency-says-covid-disruptions
June 15, 2022 - Newspaper/Magazine Article
CMS proposal to suppress hospital safety data angers advocates — agency says COVID disruptions, staff shortages hamper ability to fairly score poor performers.
Citation Text:
CMS proposal to suppress hospital safety data angers advocates — agency says COVID dis…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
July 01, 2004 - Misuse
Eighteen hours after infusion, the patient developed severe bleeding and hemodynamic instability requiring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - Over the next 10 minutes, the child’s cardiovascular status deteriorated, requiring epinephrine.
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psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - This is because the Universal Protocol does not differentiate between types of cases requiring imaging … For example, a change in hospital policy requiring imaging to be present in the operating suite prior
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - For patients requiring intermittent paracentesis for symptom relief, it would also be important to ensure … they are taking diuretic therapy or not requiring an increase in that therapy.
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - are also known as critical values, or more accurately as "alert" values,
since some reflect errors requiring … immediate correction rather than clinical conditions requiring immediate
treatment.
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psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - However, he rapidly
experienced further respiratory decompensation requiring intubation and mechanical … ventilation, as well as
hemodynamic compromise requiring vasopressor support.
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - hospital course was marked by multiorgan failure, septic shock, and spontaneous bowel
perforation requiring … antibiotics are warranted, rather than relying on evidence-based
criteria), and health care system factors (requiring
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - an interruption.(13) Consequently, inadequate laboratory test result follow-up is a system problem
requiring … Inadequate laboratory test result follow-up is a system problem requiring a system solution.
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - potential for medical errors.( 12 ) In 2005, the Joint Commission issued a National Patient Safety Goal requiring … error described in the present case may have been prevented with the use of a standardized checklist requiring
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psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
June 17, 2010 - beta-glucuronidase in the newborn intestine and, now lipid soluble again, is reabsorbed into the portal circulation, requiring … isoimmunization, maternal antibody can persist for months, and can continue to cause hemolysis, sometimes requiring