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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39697/psn-pdf
    January 04, 2011 - Compliance with guidelines to prevent surgical site infections: as simple as 1-2-3? … Compliance with guidelines to prevent surgical site infections: As simple as 1-2-3? … https://psnet.ahrq.gov/issue/compliance-guidelines-prevent-surgical-site-infections-simple-1-2-3 This … despite the existence of a positive safety climate, adherence to recommended prophylaxis for surgical site … https://psnet.ahrq.gov/issue/compliance-guidelines-prevent-surgical-site-infections-simple-1-2-3 https
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41931/psn-pdf
    December 19, 2012 - Preventing wrong-site surgery in Minnesota: a 5-year journey. … https://psnet.ahrq.gov/issue/preventing-wrong-site-surgery-minnesota-5-year-journey Discussing a 5-year … effort to report, analyze, and reduce wrong-site procedures, this magazine article details the lessons … https://psnet.ahrq.gov/issue/preventing-wrong-site-surgery-minnesota-5-year-journey https://psnet.ahrq.gov … issue/adverse-health-events-minnesota-15th-annual-public-report https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41765/psn-pdf
    October 17, 2012 - Differences in medication errors between central and remote site telepharmacies. … Differences in medication errors between central and remote site telepharmacies. … https://psnet.ahrq.gov/issue/differences-medication-errors-between-central-and-remote-site-telepharmacies … Medication error rates at community pharmacies (with pharmacists on-site) were similar to rates at … https://psnet.ahrq.gov/issue/differences-medication-errors-between-central-and-remote-site-telepharmacies
  4. psnet.ahrq.gov/glossary/swiss-cheese-model
    September 13, 2021 - For example, if the hazard were wrong-site surgery, slices of the cheese might include conventions for … identifying sidedness on radiology tests, a protocol for signing the correct site when the surgeon and … first meet, and a second protocol for reviewing the medical record and checking the previously marked site … For some serious events (e.g., operating on the wrong site or wrong person), even though the holes will … might mislabel a film (or simply hang it backwards and a hurried surgeon not notice), "signing the site
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60539/psn-pdf
    July 10, 2017 - Understanding facilitators and barriers to care transitions: insights from Project ACHIEVE Site Visits … Understanding facilitators and barriers to care transitions: insights from Project ACHIEVE Site Visits … psnet.ahrq.gov/issue/understanding-facilitators-and-barriers-care-transitions-insights-project- achieve-site-visits … In this study, site visits were conducted at 22 healthcare organization across the United State to determine … psnet.ahrq.gov/issue/understanding-facilitators-and-barriers-care-transitions-insights-project-achieve-site-visits
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40637/psn-pdf
    October 03, 2012 - Surgical site infections in colon surgery: the patient, the procedure, the hospital, and the surgeon … Surgical site infections in colon surgery: the patient, the procedure, the hospital, and the surgeon … https://psnet.ahrq.gov/issue/surgical-site-infections-colon-surgery-patient-procedure-hospital-and-surgeon … Surgical site infection rates varied widely among individual surgeons in this Swiss study. … https://psnet.ahrq.gov/issue/surgical-site-infections-colon-surgery-patient-procedure-hospital-and-surgeon
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40142/psn-pdf
    April 04, 2011 - Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. … Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. … https://psnet.ahrq.gov/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site … https://psnet.ahrq.gov/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site-surgery … https://psnet.ahrq.gov/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site-surgery
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38459/psn-pdf
    October 03, 2012 - Identifying opportunities for quality improvement in surgical site infection prevention. … Identifying opportunities for quality improvement in surgical site infection prevention. … https://psnet.ahrq.gov/issue/identifying-opportunities-quality-improvement-surgical-site-infection-prevention … and infection control at seven hospitals to highlight thematic strategies for preventing surgical site … https://psnet.ahrq.gov/issue/identifying-opportunities-quality-improvement-surgical-site-infection-prevention
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40201/psn-pdf
    February 09, 2011 - Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site … Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site … ://psnet.ahrq.gov/issue/use-anatomic-marking-form-alternative-universal-protocol-preventing-wrong- site-wrong … https://psnet.ahrq.gov/issue/use-anatomic-marking-form-alternative-universal-protocol-preventing-wrong-site-wrong … https://psnet.ahrq.gov/issue/use-anatomic-marking-form-alternative-universal-protocol-preventing-wrong-site-wrong
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46157/psn-pdf
    June 07, 2017 - Proactive risk assessment of surgical site infections in ambulatory surgery centers. … Proactive Risk Assessment of Surgical Site Infections in Ambulatory Surgery Centers. … https://psnet.ahrq.gov/issue/proactive-risk-assessment-surgical-site-infections-ambulatory-surgery-centers … This study reports on the use of a prospective risk assessment tool to identify risks for surgical site … https://psnet.ahrq.gov/issue/proactive-risk-assessment-surgical-site-infections-ambulatory-surgery-centers
  11. psnet.ahrq.gov/issue/factors-predicting-change-hospital-safety-climate-and-capability-multi-site-patient-safety
    February 01, 2011 - Factors predicting change in hospital safety climate and capability in a multi-site … Factors predicting change in hospital safety climate and capability in a multi-site patient safety collaborative … Factors predicting change in hospital safety climate and capability in a multi-site patient safety collaborative
  12. psnet.ahrq.gov/issue/simulation-systems-testing-program-using-hfmea-methodology-can-effectively-identify-and
    January 03, 2017 - program using HFMEA methodology can effectively identify and mitigate latent safety threats for a new on-site … program using HFMEA methodology can effectively identify and mitigate latent safety threats for a new on-site … program using HFMEA methodology can effectively identify and mitigate latent safety threats for a new on-site
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41466/psn-pdf
    June 20, 2012 - Factors predicting change in hospital safety climate and capability in a multi-site patient safety collaborative … Factors predicting change in hospital safety climate and capability in a multi-site patient safety collaborative … https://psnet.ahrq.gov/issue/factors-predicting-change-hospital-safety-climate-and-capability-multi-site … https://psnet.ahrq.gov/issue/factors-predicting-change-hospital-safety-climate-and-capability-multi-site-patient-safety … https://psnet.ahrq.gov/issue/factors-predicting-change-hospital-safety-climate-and-capability-multi-site-patient-safety
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47605/psn-pdf
    January 17, 2019 - assessment-incorrect-surgical-procedures-within-and-outside-operating-room- follow-study-us The Joint Commission and National Quality Forum both consider wrong-site … assessment-incorrect-surgical-procedures-within-and-outside-operating-room-follow-study-us https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov … /primer/never-events https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43257/psn-pdf
    August 14, 2014 - Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance … Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance … https://psnet.ahrq.gov/issue/barriers-and-success-factors-implementation-multi-site-prospective-adverse … https://psnet.ahrq.gov/issue/barriers-and-success-factors-implementation-multi-site-prospective-adverse-event-surveillance … https://psnet.ahrq.gov/issue/barriers-and-success-factors-implementation-multi-site-prospective-adverse-event-surveillance
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45770/psn-pdf
    January 25, 2017 - Understanding patient-centred readmission factors: a multi-site, mixed-methods study. … Understanding patient-centred readmission factors: a multi-site, mixed-methods study. … https://psnet.ahrq.gov/issue/understanding-patient-centred-readmission-factors-multi-site-mixed-methods … https://psnet.ahrq.gov/issue/understanding-patient-centred-readmission-factors-multi-site-mixed-methods-study … https://psnet.ahrq.gov/issue/understanding-patient-centred-readmission-factors-multi-site-mixed-methods-study
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40025/psn-pdf
    December 21, 2014 - Evaluating an evidence-based bundle for preventing surgical site infection. … Evaluating an evidence-based bundle for preventing surgical site infection: a randomized trial. … https://psnet.ahrq.gov/issue/evaluating-evidence-based-bundle-preventing-surgical-site-infection Checklists … This randomized controlled trial attempted to extend the checklist approach to prevention of surgical site … https://psnet.ahrq.gov/issue/evaluating-evidence-based-bundle-preventing-surgical-site-infection https
  18. psnet.ahrq.gov/web-mm/mark-my-limb
    February 10, 2015 - Lessons learned: wrong site surgery. … A follow-up review of wrong site surgery. … Joint Commission on Accreditation of Healthcare Organizations Web site. … Available at: [ go to related site ]. … Joint Commission on Accreditation of Healthcare Organizations Web site
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37009/psn-pdf
    March 18, 2010 - Doing the "right" things to correct wrong-site surgery. … March 18, 2010 Patient Safety Advisory https://psnet.ahrq.gov/issue/doing-right-things-correct-wrong-site-surgery … This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results … https://psnet.ahrq.gov/issue/doing-right-things-correct-wrong-site-surgery https://psnet.ahrq.gov/issue
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46736/psn-pdf
    December 17, 2018 - https://psnet.ahrq.gov/issue/back-basics-universal-protocol Wrong-site, wrong-procedure, and wrong-patient … https://psnet.ahrq.gov/issue/back-basics-universal-protocol https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery … enhanced-time-out-improved-communication-process https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

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