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psnet.ahrq.gov/issue/understanding-enablers-and-barriers-implementing-patient-led-escalation-system-qualitative
January 18, 2023 - February 28, 2024
Society of Critical Care Medicine Guidelines on Recognizing and Responding … July 15, 2020
Making Healthcare Safer III.
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psnet.ahrq.gov/issue/health-literacy-universal-precautions-toolkit-second-edition
July 01, 2015 - September 16, 2015
Making Healthcare Safer III. … December 9, 2009
Industrial and Systems Engineering and Health Care: Critical Areas of … October 2, 2013
Making Health Care Safer: A Critical Analysis of Patient Safety Practices … August 19, 2020
Making Healthcare Safer III.
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psnet.ahrq.gov/issue/complexity-team-training-what-we-have-learned-aviation-and-its-applications-medicine
December 09, 2009 - September 23, 2020
Making Health Care Safer II: An Updated Critical Analysis of the Evidence … October 29, 2008
How will we know patients are safer? … October 24, 2007
Building safer systems by ecological design: using restoration science … Advancing Patient Safety: Reviews From the Agency for Healthcare Research and Quality's Making Healthcare Safer … III Report.
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psnet.ahrq.gov/node/49653/psn-pdf
May 01, 2012 - lines placed outside the hospital in patients
received on transfer (and writing on the dressing), (iii … handoffs between nurses (e.g., does the patient have a central line; do they need a central line), and
(iii … training, and a safety culture that reduce the risk of injury by making it easier to
know what to do and safer … medications;
the residents consider the physiology and greatest source of danger for the patient that day), (iii … Professor, University of Cincinnati College of Medicine, Division of Pulmonary, Critical
Care, and
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psnet.ahrq.gov/issue/iatrogenic-delirium-and-coma-near-miss
September 23, 2020 - July 26, 2023
Perspective
Making Healthcare Safer III Report
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - lines placed outside the hospital in patients received on transfer (and writing on the dressing), (iii … handoffs between nurses (e.g., does the patient have a central line; do they need a central line), and (iii … training, and a safety culture that reduce the risk of injury by making it easier to know what to do and safer … medications; the residents consider the physiology and greatest source of danger for the patient that day), (iii … Render, MD Veterans Health Administration, National Program Director, Critical Care, Lung Disease
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - evidence reviews of existing and
emerging PSPs (interventions)
► MHS I: 2001
► MHS II: 2013
► MHS III … Response
Systems: Rapid Review
19
Bradford Winters, MD, PhD (Author & Presenter)
Professor of Critical … Rapid Response Systems that Aim to Mitigate
Failure to Rescue in General Hospital Wards
• MHS III … Primary Removed
hospitalist
physician, added
critical care nurse
Hospital
Standardized
Mortality … Research 2023;16:383-394
Opioid Stewardship Interventions in
Healthcare Facilities or Systems
• MHS III
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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - that allow for easy reporting of events, (ii) standardizing performance review and
assessment, and (iii … clinicians consider all appropriate diagnoses.(13,14)
Balancing systems and individual accountability is critical … Lesser CS, Lucey CR, Egener B, Braddock CH III, Linas SL, Levinson W. … Reiter CE III, Pichert JW, Hickson GB. … Commentary: how can we make diagnosis safer? Acad Med. 2012;87:135-138.
[go to PubMed]
14.
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psnet.ahrq.gov/issue/safety-ii-and-study-healthcare-safety-routines-two-paths-forward-research
May 25, 2022 - Advancing Patient Safety: Reviews From the Agency for Healthcare Research and Quality's Making Healthcare Safer … III Report.
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psnet.ahrq.gov/issue/do-quality-and-safe-care-champions-community-nursing-teams-positively-impact-patients
October 19, 2022 - Advancing Patient Safety: Reviews From the Agency for Healthcare Research and Quality's Making Healthcare Safer … III Report.
-
psnet.ahrq.gov/node/60173/psn-pdf
March 30, 2020 - We spoke with
them about their role in the development of the Making Healthcare Safer III Report and … current role that you play as well
as the role that you played in the creation of the Making Healthcare Safer … conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
https://psnet.ahrq.gov/issue/making-healthcare-safer-iii … SH: If someone is not familiar with the Making Healthcare Safer Report, what is your short
explanation … SH: Were there any particular technologies in the report that address critical new or emerging
issues
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psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
July 17, 2024 - that allow for easy reporting of events, (ii) standardizing performance review and assessment, and (iii … clinicians consider all appropriate diagnoses.( 13,14 ) Balancing systems and individual accountability is critical … Lesser CS, Lucey CR, Egener B, Braddock CH III, Linas SL, Levinson W. … Reiter CE III, Pichert JW, Hickson GB. … Commentary: how can we make diagnosis safer? Acad Med. 2012;87:135-138. [go to PubMed] 14.
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psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - Care Medicine
and the Society of Critical Care Medicine.(6) The guidelines recommend careful planning … factor for errors and adverse
events.(12) Moreover, handover within and between units can result in critical … team; (ii) assessment
of the patient after transport to determine any deterioration in condition; (iii … Warren J, Fromm Jr RE, Orr RA, Rotello LC, Mathilda HM; American College of Critical Care Medicine. … To Err Is Human: Building a Safer Health System.
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psnet.ahrq.gov/primer/alert-fatigue
September 07, 2019 - problem is that clinicians then ignore both the bothersome, clinically meaningless alarms and the critical … Clinicians generally override the vast majority of CPOE warnings, even "critical" alerts that warn … The Making Healthcare Safer III report outlines several patient safety practices to address alert fatigue … Tailor alerts to patient characteristics and critical integrated clusters of physiologic indicators.
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psnet.ahrq.gov/node/49775/psn-pdf
November 01, 2016 - McGreevey III, MD
Order sets are intended to increase consistent, evidence-based practice, prevent errors … Adherence to established principles of order set design, decision support, and governance is critical … McGreevey JD III. Order sets in electronic health records: principles of good practice. … SAFER Guides: Computerized Provider Order Entry With Decision Support. … pubmed/23276846
http://www.ncbi.nlm.nih.gov/pubmed/23457151
https://www.healthit.gov/sites/default/files/safer
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psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
June 16, 2021 - Care Medicine and the Society of Critical Care Medicine.( 6 ) The guidelines recommend careful planning … factor for errors and adverse events.( 12 ) Moreover, handover within and between units can result in critical … team; (ii) assessment of the patient after transport to determine any deterioration in condition; (iii … Warren J, Fromm Jr RE, Orr RA, Rotello LC, Mathilda HM; American College of Critical Care Medicine. … To Err Is Human: Building a Safer Health System.
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psnet.ahrq.gov/node/33749/psn-pdf
April 01, 2013 - A policy that makes today's patients a bit safer at the
cost of larger harm to patients later would … Communication failures in patient sign-out
and suggestions for improvement: a critical incident analysis … Fletcher KE, Davis SQ, Underwood W III, Mangrulkar RA, McMahon LF Jr, Saint S. … Fletcher KE, Underwood W III, Davis SQ, Mangrulkar RS, McMahon LF Jr, Saint S.
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psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - the areas of focus in the Agency for Healthcare Research and Quality (AHRQ) report Making Healthcare Safer … III: A Critical Analysis of Existing and Emerging Patient Safety Practices . 1 Although medication … interventions provide prescribers with medication warning alerts and alternative medications that are safer … of opioid prescribing practices related to workers’ compensation in Washington State reported that safer … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices .
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psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
February 15, 2017 - The critical care provider consulted a nephrologist, and both agreed the severe symptomatic hyponatremia … thiazides in patients with a history of thiazide-induced hyponatremia; (ii) start with a low dose; (iii … Take-Home Points
References
Related Resources From the Same Author(s)
Safer … November 15, 2023
Guidelines on Human Factors in Critical Situations 2023. … Order Set Change and Critical Limb Ischemia
January 1, 2019
Another tragic
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psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
December 01, 2017 - McGreevey III, MD | November 1, 2016
View more articles from the same authors. … McGreevey III, MD Order sets are intended to increase consistent, evidence-based practice, prevent errors … Adherence to established principles of order set design, decision support, and governance is critical … McGreevey JD III. Order sets in electronic health records: principles of good practice. … SAFER Guides: Computerized Provider Order Entry With Decision Support.