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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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