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psnet.ahrq.gov/node/49722/psn-pdf
December 01, 2014 - Another, safer design could involve consolidating all bed status information, including
lock status, … Unlike in
aviation where safety-critical changes are quickly communicated and acted upon across the … infusion pump.(14) In summary, medical
device and health care industries can produce safer products … By designing safer medical devices based on human factors engineering principles and methods,
patient … Pennathur PR, Thompson D, Abernathy JH III, et al.
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psnet.ahrq.gov/issue/ahrq-health-literacy-universal-precautions-toolkit-0
May 26, 2010 - January 7, 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
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psnet.ahrq.gov/node/836850/psn-pdf
March 31, 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 safety … 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/periodic-issue/periodic-issue-467
December 18, 2024 - This article describes the Safety I, Safety II, and Safety III frameworks and how each can support safety … Safety II emphasizes resilience and clinicians’ adaptability, while Safety III integrates system design … accompanying editorial describes harm reduction strategies providers can offer, including overdose prevention, safer … supply, and safer injection strategies. … Safety II emphasizes resilience and clinicians’ adaptability, while Safety III integrates system design
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psnet.ahrq.gov/node/836942/psn-pdf
April 27, 2022 - patient was
assigned an American Society of Anesthesiologists physical status classification of level III … has led to under-reporting of medication errors and relatively little
attention being paid to this critical … psnet.ahrq.gov/issue/institute-safe-medication-practices
https://psnet.ahrq.gov/issue/err-human-building-safer-health-system … setting presents unique challenges and obstacles compared to
other hospital settings due to its time-critical … The Critical Care Safety Study: The incidence and
nature of adverse events and serious medical errors
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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - Performance analysis focused on errors, and trained users of the 3 pumps had a total of 10, 18, and
42 critical … viewpoint arises when we start looking at devices, software, and even architecture through a more
critical … The Role of Health Care Organizations
Health care organizations can use HFE to select and deploy safer … pump system is not being replaced, an organization can use HFE methods to make its
existing system safer … from each IV bag all the
way to the IV catheter—beyond simply placing a label every 6 inches, and (iii
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psnet.ahrq.gov/web-mm/code-blue-where
March 30, 2020 - When the critical care nurse and the rest of the code team arrived, they attempted to hook the patient … Ironically, casinos or airports, with their robust public access defibrillator systems, may be safer … Critical Care Medicine. 1986;14:99-104. [go to PubMed] 12. Adams BD, Easty DM, Stuffel E, et al. … Resources From the Same Author(s)
Perspective
Making Healthcare Safer … III Report
March 30, 2020
Natural history of retained surgical items supports
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psnet.ahrq.gov/node/49757/psn-pdf
April 01, 2016 - trainees to critically examine what they see every day on rounds and at the bedside, we can
make patients safer … Before attempting to define situational awareness for any type of clinical practice, it is first critical … understand what it is about a situation that the physician must be aware of.(6) In fact, even more critical … Reiff DA, Shoultz T, Griffin RL, Taylor B, Rue LW III.
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - dose into the desired interval for administration (in the described case, three times daily), and (iii … providers continue to adopt EHRs with CPOE, they should consider strongly implementing automated CDS at the critical … software that can accurately convert this message into a standard data format (often HL7 standard), and (iii … Computerized physician order entry and medication errors in a pediatric critical care unit. … June 14, 2017
Electronic prescribing in pediatrics: toward safer and more effective medication
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psnet.ahrq.gov/node/33815/psn-pdf
September 01, 2016 - https://psnet.ahrq.gov//#ref2
https://psnet.ahrq.gov//#ref3
emergency departments (EDs) and pediatric critical … usability and efficacy trials, such
evaluations should not be limited to academic medical settings; (iii … Medication error reporting in rural critical access
hospitals in the North Dakota Telepharmacy Project … Lewis TL, Wyatt JC. mHealth and mobile medical apps: a framework to assess risk and promote safer
use
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psnet.ahrq.gov/node/33829/psn-pdf
March 01, 2017 - of what they've accomplished and to make themselves
available to other members for consultation; (iii … as the basis for motivating action and directing
decision-making about how to pursue improvement is critical … Prior research has shown that, particularly where many actions would be
beneficial, it is critical not … To Err Is Human: Building a Safer Health System.Washington,
DC: Committee on Quality of Health Care
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psnet.ahrq.gov/curated-library/patient-and-family-engagement-long-term-care
April 10, 2024 - the COVID-19 pandemic affected partnership with patients and families, ultimately highlighting the critical … The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul. … the COVID-19 pandemic affected partnership with patients and families, ultimately highlighting the critical … Book/Report
The Economics of Patient Safety Part III: Long-term Care: Valuing Safety … infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer
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psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
May 28, 2020 - We’ve also been advancing innovation to spur the development of safer medical devices. … irreversibly debilitating conditions, as well as a new program that we are establishing called the Safer … program, devices that don’t meet all the criteria to be considered a “breakthrough,” but otherwise may be safer … This can provide us with critical information more quickly and more efficiently. … Class III: Devices that “sustain or support life, are implanted, or present potential high risk of illness
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psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
May 28, 2020 - Class III: Devices that “sustain or support life, are implanted, or present potential high risk of illness … We’ve also been advancing innovation to spur the development of safer medical devices. … irreversibly debilitating conditions, as well as a new program that we are establishing called the Safer … program, devices that don’t meet all the criteria to be considered a “breakthrough,” but otherwise may be safer … This can provide us with critical information more quickly and more efficiently.
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psnet.ahrq.gov/node/49493/psn-pdf
November 01, 2005 - Since critical care units have an entirely different level
of acuity, their practice competencies are … In this case, a
nurse with primary roles in non-critical care—by his own admission not qualified to … work in critical
care—floated to a unit where he lacked necessary competencies. … using a root cause analysis (RCA),
(ii) disclosure to the patient and family with an apology, and (iii … To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press;
2000.
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - Another, safer design could involve consolidating all bed status information, including lock status, … Unlike in aviation where safety-critical changes are quickly communicated and acted upon across the entire … infusion pump.( 14 ) In summary, medical device and health care industries can produce safer products … By designing safer medical devices based on human factors engineering principles and methods, patient … Pennathur PR, Thompson D, Abernathy JH III, et al.
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psnet.ahrq.gov/node/49677/psn-pdf
February 01, 2013 - utilized); (ii) improper decision to use the line, despite inability to withdraw blood from it; and
(iii … Error #1
Best practice for CVC placement mandates the use of ultrasound as a critical element for safety … Adequate
supervision and the use of simulators are critical adjuncts to proper procedural training. … Real-time ultrasound-guided subclavian vein cannulation
versus the landmark method in critical care … Making Health Care Safer: a Critical Analysis of Patient Safety Practices: Summary.
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psnet.ahrq.gov/web-mm/wrong-channel
February 01, 2003 - Performance analysis focused on errors, and trained users of the 3 pumps had a total of 10, 18, and 42 critical … Another viewpoint arises when we start looking at devices, software, and even architecture through a more critical … create human factors design standards for all future infusion devices.( 10 ) Designing efficient, yet safer … pump system is not being replaced, an organization can use HFE methods to make its existing system safer … from each IV bag all the way to the IV catheter—beyond simply placing a label every 6 inches, and (iii
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psnet.ahrq.gov/node/49863/psn-pdf
May 01, 2019 - decrease in surgical morbidity and annual mortality; (ii) a reduction in hospital-acquired conditions; (iii … Critical role of the surgeon–anesthesiologist relationship for patient safety. … Medical team training improves team performance:
AOA critical issues. … Safer paediatric surgical teams: a 5-year evaluation
of crew resource management implementation and … Such understanding is conveyed by repeating critical parts of the
message.
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psnet.ahrq.gov/issue/surveys-patient-safety-culturetm-sopsr-ambulatory-surgery-center-survey-2021-user-database
June 01, 2022 - March 6, 2005
Making Healthcare Safer III. … November 18, 2015
Making Health Care Safer: A Critical Analysis of Patient Safety Practices … November 8, 2023
Making Healthcare Safer IV: A Continuous Updating of Patient Safety