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psnet.ahrq.gov/issue/no-simple-fix-fixation-errors-cognitive-processes-and-their-clinical-applications
February 10, 2012 - non-technical skills used by anaesthetic technicians in critical incidents reported to the Australian Incident Monitoring
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psnet.ahrq.gov/issue/applying-toyota-production-system-using-patient-safety-alert-system-reduce-error
June 21, 2015 - Commentary
Applying the Toyota Production System: using a patient safety alert system to reduce error.
Citation Text:
Furman C, Caplan RA. Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf. 2007;33(7):376-386.
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psnet.ahrq.gov/issue/diagnostic-decision-making-emergency-department
December 16, 2020 - Review
Diagnostic decision-making in the emergency department.
Citation Text:
Medford-Davis LN, Singh H, Mahajan P. Diagnostic decision-making in the emergency department. Pediatr Clin North Am. 2018;65(6):1097-1105. doi:10.1016/j.pcl.2018.07.003.
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DOI …
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psnet.ahrq.gov/issue/first-year-nursing-students-viewpoints-about-compromised-clinical-safety
July 15, 2020 - November 16, 2022
State policies for prescription drug monitoring programs and adverse
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psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
January 29, 2021 - continuous positive airway pressure via face mask, and sitting him upright might have stabilized the situation … The American Society of Anesthesiology now recommends the use of quantitative neuromuscular monitoring … recovery from neuromuscular blocking drugs prior to extubation. 26 This quantitative neuromuscular monitoring … Monitoring the patient’s respiration and oxygenation is especially important immediately following extubation … Vigilant monitoring in this case led to the hypoxemia being treated expeditiously, so the patient did
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psnet.ahrq.gov/periodic-issue/periodic-issue-279
February 10, 2021 - Preventable medication harm occurred most frequently during medication prescribing and monitoring. … Clinical decision support (CDS) alerts can improve patient safety, and prior research suggests that monitoring … These findings highlight the need for improvements in alert design, implementation, and monitoring of … Preventable medication harm occurred most frequently during medication prescribing and monitoring. … This situation can reduce the effectiveness of monitoring patients on shared devices and introduce other
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psnet.ahrq.gov/issue/imitating-incidents-how-simulation-can-improve-safety-investigation-and-learning-adverse
February 28, 2024 - May 20, 2019
Measurement and monitoring of safety: impact and challenges of putting a
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psnet.ahrq.gov/issue/improving-patient-safety-lessons-rock-climbing
July 10, 2024 - Commentary
Improving patient safety: lessons from rock climbing.
Citation Text:
Robertson N. Improving patient safety: lessons from rock climbing. Clin Teach. 2012;9(1):41-4. doi:10.1111/j.1743-498X.2011.00485.x.
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psnet.ahrq.gov/issue/cardiac-arrest-during-anesthesia
January 19, 2011 - December 2, 2020
Nonoperating room anaesthesia: safety, monitoring, cognitive aids and
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psnet.ahrq.gov/issue/attending-work-hour-restrictions-it-time
November 28, 2012 - Commentary
Attending work hour restrictions: is it time?
Citation Text:
Hyman NH. Attending work hour restrictions: is it time? Arch Surg. 2009;144(1):7-8. doi:10.1001/archsurg.2008.518.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/issue/evaluating-teamwork-simulated-obstetric-environment
November 04, 2009 - January 10, 2017
System errors in intrapartum electronic fetal monitoring: a case review
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psnet.ahrq.gov/issue/quality-reporting-studies-evaluating-time-diagnosis-systematic-review-paediatrics
March 29, 2010 - April 26, 2023
Interventions to reduce medication dispensing, administration, and monitoring
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psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
April 01, 2003 - Standards for Basic Anesthetic Monitoring.
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - treatment decisions, other team members (the nurse in this case) have
responsibility for performance monitoring … and integrity in clinical work with patients and members of clinical teams.(12) Physicians' self-
monitoring … shape decisions for future action.(20)
What Steps Should Any Health Care Professional Take in This Situation
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psnet.ahrq.gov/issue/systematic-review-patient-tracking-systems-use-pediatric-emergency-department
August 03, 2022 - Review
A systematic review of patient tracking systems for use in the pediatric emergency department.
Citation Text:
Dobson I, Doan Q, Hung G. A systematic review of patient tracking systems for use in the pediatric emergency department. J Emerg Med. 2013;44(1):242-8. doi:10.1016/j.jem…
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psnet.ahrq.gov/issue/pediatric-emergency-nurses-self-reported-medication-safety-practices
March 03, 2019 - March 15, 2023
Physicians' perspectives regarding prescription drug monitoring program
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psnet.ahrq.gov/issue/application-surgical-safety-standards-robotic-surgery-five-principles-ethics-nonmaleficence
October 19, 2022 - February 24, 2012
Practice Advisory on Intraoperative Awareness and Brain Function Monitoring
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psnet.ahrq.gov/issue/smart-pump-custom-concentrations-without-hard-low-concentration-alerts-can-lead-patient-harm
October 17, 2018 - January 24, 2018
Remote CPOE error—a situation that's more than remotely possible.
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psnet.ahrq.gov/issue/coaching-debriefer-peer-coaching-improve-debriefing-quality-simulation-programs
July 31, 2019 - March 6, 2024
Alternatives to opioid education and a prescription drug monitoring program
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psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
January 12, 2022 - There was an ongoing need for increased vigilance in patient monitoring. … Quality
April 26, 2023
Perspective
Surveillance Monitoring