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psnet.ahrq.gov/node/43115/psn-pdf
December 18, 2014 - Clostridium difficile was responsible for more than 12% of infections,
highlighting the importance of
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psnet.ahrq.gov/issue/no-fault-compensation-medical-injuries-prospect-error-prevention
May 20, 2015 - encourage error reporting and could be linked to reforms that make institutions, rather than individuals, responsible
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psnet.ahrq.gov/curated-library/rapid-response-systems
September 15, 2024 - Breadcrumb
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Created By: AHRQ
Date Created: January 24, 20…
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psnet.ahrq.gov/web-mm/feeling-no-pain
August 30, 2023 - Similarly, the person responsible for taking the history might be faulted for not probing sufficiently … Most analyses of error determine that the hospital, by assigning the work schedule, was responsible and … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/glucose-roller-coaster
February 02, 2022 - and perils of "cross-coverage," the management of patients by physicians other than those primarily responsible … Moreover, our nightfloat intern may be responsible for as many as 40-60 patients (including some in the … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/issue/identification-root-causes-emergency-diagnostic-imaging-delays-three-canadian-hospitals
July 02, 2014 - conducted a root cause analysis of diagnostic imaging delays and found that current practices were responsible
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psnet.ahrq.gov/issue/analysis-human-performance-deficiencies-associated-surgical-adverse-events
April 15, 2016 - This study found that those types of human errors were responsible for 51.6% of 188 surgical adverse
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psnet.ahrq.gov/issue/fostering-transparency-outcomes-quality-safety-and-costs
January 29, 2015 - recommends ways to enhance the use of quality and safety measures, including establishing an entity responsible
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psnet.ahrq.gov/web-mm/check-bags
January 03, 2017 - the ICU is usually less than or equal to 2:1, while a single nurse on a medical-surgical unit may be responsible … When errors occur, the responsible staff member should be an active participant in an evaluative process … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/node/49409/psn-pdf
July 01, 2003 - Similarly, the person responsible for taking the
history might be faulted for not probing sufficiently … Most analyses of
error determine that the hospital, by assigning the work schedule, was responsible … The authors are solely
responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/issue/abusive-supervision-systematic-review-and-fundamental-rethink
May 18, 2022 - While leaders and supervisors are responsible for ensuring a professional and respectful work environment
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psnet.ahrq.gov/issue/study-multisite-prospective-adverse-event-surveillance-system
October 16, 2019 - rates among the five hospitals and concluded that event detection among the trigger event reviewers was responsible
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - Some smaller
hospitals require ICU nurses to be responsible for watching monitors for patients on other … If the responsible health care provider has
questions about a patient's rhythm history, how the patient … Each facility is responsible for identifying the response process. … The authors are solely
responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
September 25, 2019 - Five days later, the bone pathologist responsible for the case contacted the orthopedic surgery service … To accomplish this, the responsible pathologist should seek intradepartmental consensus or external expert … These diagnoses are conspicuously flagged to alert the responsible pathologist to the presence of a preliminary … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/issue/open-notes-shines-light-errors-patient-medical-records-will-new-rule-lead-flood-correction
March 27, 2024 - June 1, 2022
When we're all responsible for a patient's death, no one is.
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psnet.ahrq.gov/node/44709/psn-pdf
November 18, 2016 - physicians, and
variation in physicians' communication and teamwork skills were the main factors deemed responsible
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psnet.ahrq.gov/web-mm/harm-alarm-fatigue
February 14, 2018 - The resident physician responsible for the patient overnight was also paged about the alarms. … Since one monitor watcher is responsible for watching as many as 40 patients' data, only one ECG lead … the nurse responded to these alarms by checking on the patient (multiple times) and contacting the responsible … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/node/49543/psn-pdf
September 01, 2007 - involved, including physicians, nurses, and pharmacists, often have divergent expectations about who is
responsible … Second, although the medication history was later corrected by the anesthesiologist, the clinician
responsible … design a robust medication reconciliation process, first define steps involved and decide who
should be responsible … The authors are solely
responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/node/49513/psn-pdf
July 01, 2006 - clear standards for patient
assessment, including the elements of an assessment, its timing, and the responsible … The transport personnel are responsible for ensuring
the nurse completes the ticket and that the ticket … Who is responsible for this assessment?
What is the recommended timing for this assessment? … The authors are solely
responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - occurs, best practices must also address the issue of who documents the communication—the individual responsible … Best practices suggest that the time out be led by the physician responsible for performing the procedure … Protocol and time out are documented, but care must be taken to not make one member of the team feel responsible … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not