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psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
December 15, 2024 - support, professional review, and collegial feedback, as well as access to patient safety experts and risk … The second tier involves trained peer support persons embedded in high-risk clinical units to monitor … support, trigger debriefings, and access to other organizational resources such as patient safety or risk
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psnet.ahrq.gov/node/74044/psn-pdf
November 03, 2021 - challenges-requiring-five-characters-during-adc-drug-searches-override
https://psnet.ahrq.gov/issue/documentation-bad-habits-shortcuts-electronic-records-pose-risk
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psnet.ahrq.gov/node/838141/psn-pdf
September 21, 2022 - new-covid-boosters-look-lot-old-ones-doctors-worry-could-lead-errors
Look-alike sound-alike packaging is a known risk
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psnet.ahrq.gov/node/43554/psn-pdf
June 21, 2015 - psnet.ahrq.gov/issue/surgical-checklist-implementation-project-impact-variable-who-checklist-compliance-risk
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psnet.ahrq.gov/node/61070/psn-pdf
October 28, 2020 - perioperative use of radiofrequency technology was associated with fewer
retained sponges and decreased risk
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psnet.ahrq.gov/node/837707/psn-pdf
July 20, 2022 - J Patient Saf Risk Manage.
2022;27(2):56-58. doi:10.1177/25160435221077778.
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psnet.ahrq.gov/node/46242/psn-pdf
June 21, 2017 - applying-toyota-production-system-principles-psychiatric-hospital-making-transfers-safer-and
https://psnet.ahrq.gov/issue/what-near-misses-tell-us-about-risk-and-safety-mental-health-care
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psnet.ahrq.gov/node/42100/psn-pdf
March 13, 2013 - of duplicate records (a single patient having multiple medical records within the same
system) is a risk
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psnet.ahrq.gov/node/44785/psn-pdf
January 27, 2016 - psnet.ahrq.gov/issue/reducing-adverse-drug-events-related-opioids-implementation-guide
Opioids are high-risk
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psnet.ahrq.gov/node/50818/psn-pdf
January 22, 2020 - The survey found that risk of burnout was
associated with reported stress, sleepiness, dissatisfaction
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psnet.ahrq.gov/node/39318/psn-pdf
June 02, 2010 - patient-and
This study used focus groups to analyze how health care professionals may minimize the risk
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psnet.ahrq.gov/node/44712/psn-pdf
December 09, 2015 - contact precautions less often, and this has raised concerns about reduced
vigilance increasing the risk
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psnet.ahrq.gov/node/50905/psn-pdf
February 19, 2020 - Patient Safety) program has been shown to be effective in
preventing inpatient falls through formal risk
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psnet.ahrq.gov/node/45251/psn-pdf
August 24, 2016 - people-blinded-what-went-wrong
Certain elements of the ambulatory surgery environment can increase risk
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psnet.ahrq.gov/node/47122/psn-pdf
June 13, 2018 - the complexity of this entirely manual process and suggest
that current practices carry significant risk
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psnet.ahrq.gov/node/837626/psn-pdf
July 06, 2022 - /frailty-gaps-care-coordination-and-preventable-adverse-events
Frail older adults are at increased risk
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psnet.ahrq.gov/node/40350/psn-pdf
April 20, 2011 - root cause analysis to identify systematic problems that resulted in incorrect assessment of
suicide risk
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psnet.ahrq.gov/node/40690/psn-pdf
August 17, 2011 - designing-safer-process-prevent-retained-surgical-sponges-healthcare-failure-mode-and-effect
https://psnet.ahrq.gov//#failuremodeandeffectanalysis
https://psnet.ahrq.gov/issue/risk-factors-retained-instruments-and-sponges-after-surgery
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psnet.ahrq.gov/node/47319/psn-pdf
October 10, 2018 - issue/standardization-compounded-oral-liquids-pediatric-patients-michigan
https://psnet.ahrq.gov/issue/risk-factors-iv-compounding-errors-when-using-automated-workflow-management-system
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psnet.ahrq.gov/node/865719/psn-pdf
May 01, 2024 - high-reliability-pediatric-heart-centers-always-working-toward-getting-better
High reliability organizations can operate in complex, high-risk