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Showing results for "standards".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45054/psn-pdf
    May 18, 2016 - Double checking: a second look. May 18, 2016 Hewitt T, Chreim S, Forster AJ. Double checking: a second look. J Eval Clin Pract. 2016;22(2):267-74. doi:10.1111/jep.12468. https://psnet.ahrq.gov/issue/double-checking-second-look Manual double checking of high-risk medication administration is a standard safety pract…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44789/psn-pdf
    April 25, 2016 - Guideline for prevention of retained surgical items. April 25, 2016 Putnam K. Guideline for prevention of retained surgical items. AORN J. 2015;102(6):P11-P13. https://psnet.ahrq.gov/issue/guideline-prevention-retained-surgical-items Retained surgical items are considered a sentinel event in perioperative care. Thi…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41484/psn-pdf
    September 26, 2012 - An institution-wide handoff task force to standardise and improve physician handoffs. September 26, 2012 Horwitz LI, Schuster KM, Thung SF, et al. An institution-wide handoff task force to standardise and improve physician handoffs. BMJ Qual Saf. 2012;21(10):863-71. https://psnet.ahrq.gov/issue/institution-wide-ha…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42998/psn-pdf
    March 05, 2014 - Exploring information chaos in community pharmacy handoffs. March 5, 2014 Chui MA, Stone JA. Exploring information chaos in community pharmacy handoffs. Res Social Adm Pharm. 2014;10(1):195-203. doi:10.1016/j.sapharm.2013.04.009. https://psnet.ahrq.gov/issue/exploring-information-chaos-community-pharmacy-handoffs …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38141/psn-pdf
    October 22, 2008 - Standardised proformas improve patient handover: audit of trauma handover practice. October 22, 2008 Ferran NA, Metcalfe AJ, O'Doherty D. Standardised proformas improve patient handover: Audit of trauma handover practice. Patient Saf Surg. 2008;2:24. doi:10.1186/1754-9493-2-24. https://psnet.ahrq.gov/issue/standar…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61052/psn-pdf
    April 01, 2019 - Inadvertent Administration of an Oral Liquid Medicine into a Vein. April 1, 2019 Farnborough, UK; Healthcare Safety Investigation Branch: April 2019. https://psnet.ahrq.gov/issue/inadvertent-administration-oral-liquid-medicine-vein Wrong route medication administration is a never event. This report examined the co…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37919/psn-pdf
    July 16, 2008 - Adverse event protocol for interventional pain medicine: the importance of an organized response. July 16, 2008 Sitzman BT. Adverse Event Protocol for Interventional Pain Medicine: The Importance of an Organized Response. Pain Medicine. 2008;9(suppl 1). doi:10.1111/j.1526-4637.2008.00446.x. https://psnet.ahrq.gov/…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39437/psn-pdf
    March 03, 2011 - Using care bundles to reduce in-hospital mortality: quantitative survey. March 3, 2011 Robb E, Jarman B, Suntharalingam G, et al. Using care bundles to reduce in-hospital mortality: quantitative survey. BMJ. 2010;340:c1234. doi:10.1136/bmj.c1234. https://psnet.ahrq.gov/issue/using-care-bundles-reduce-hospital-mort…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46334/psn-pdf
    August 09, 2017 - Maternal deaths at MetroWest hospital prompt state probes. August 9, 2017 Kowalczyk L. Boston Globe. July 29, 2017. https://psnet.ahrq.gov/issue/maternal-deaths-metrowest-hospital-prompt-state-probes Maternal death is a sentinel event. This news article reports on two incidents at one hospital that prompted inves…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35976/psn-pdf
    August 10, 2010 - Guidelines for prevention, diagnosis and treatment of ventilator-associated pneumonia (VAP) in the trauma patient. August 10, 2010 Minei JP, Nathens AB, West M, et al. Guidelines for prevention, diagnosis and treatment of ventilator- associated pneumonia (VAP) in the trauma patient. J Trauma. 2006;60(5):1106-1113.…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60998/psn-pdf
    October 07, 2020 - The slow, troubling death of the autopsy. October 7, 2020 Ashworth S. Elemental. September 22, 2020. https://psnet.ahrq.gov/issue/slow-troubling-death-autopsy The rate of autopsies – the “gold standard” of death investigation – are decreasing worldwide. This commentary highlights the lost opportunities for ho…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41103/psn-pdf
    June 15, 2012 - Quality indicators for implementation of safety promotion: towards valid and reliable global certification of local programmes. June 15, 2012 Timpka T, Nordqvist C, Festin K, et al. Quality indicators for implementation of safety promotion: towards valid and reliable global certification of local programmes. Glob …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43180/psn-pdf
    August 12, 2014 - 'Between the flags': implementing a rapid response system at scale. August 12, 2014 Hughes C, Pain C, Braithwaite J, et al. 'Between the flags': implementing a rapid response system at scale. BMJ Qual Saf. 2014;23(9):714-7. doi:10.1136/bmjqs-2014-002845. https://psnet.ahrq.gov/issue/between-flags-implementing-rapi…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46281/psn-pdf
    January 01, 2021 - Classifying adverse events in the dental office. September 6, 2017 Kalenderian E, Obadan-Udoh E, Maramaldi P, et al. Classifying Adverse Events in the Dental Office. J Patient Saf. 2021;17(6):e540-e356. doi:10.1097/PTS.0000000000000407. https://psnet.ahrq.gov/issue/classifying-adverse-events-dental-office In this …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45512/psn-pdf
    October 05, 2016 - When doctors get the wrong patient. October 5, 2016 Whitman E. Mod Healthc. September 25, 2016. https://psnet.ahrq.gov/issue/when-doctors-get-wrong-patient Misidentification of patients can result in problems such as medication administration delays, blood transfusion mismatches, and wrong-patient surgery. This ma…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35989/psn-pdf
    September 17, 2010 - Using preprinted medication order forms to improve the safety of investigational drug use. September 17, 2010 Tamer H, Shehab N. Using preprinted medication order forms to improve the safety of investigational drug use. Am J Health Syst Pharm. 2006;63(11):1022, 1025-1026, 1028. https://psnet.ahrq.gov/issue/using-p…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36234/psn-pdf
    October 21, 2010 - Conceptual Framework for the International Classification for Patient Safety Version 1.1. Final Technical Report January 2009. October 21, 2010 World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2009. https://psnet.ahrq.gov/issue/conceptual-framework-international-classification-pat…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43003/psn-pdf
    March 05, 2014 - Learning from every death. March 5, 2014 Huddleston JM, Diedrich DA, Kinsey GC, et al. Learning from every death. J Patient Saf. 2014;10(1):6-12. doi:10.1097/PTS.0000000000000053. https://psnet.ahrq.gov/issue/learning-every-death This commentary describes how design and implementation of an institutional mortality…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41234/psn-pdf
    July 02, 2014 - The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care. July 2, 2014 Wohlauer M, Arora V, Horwitz LI, et al. The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care. Acad Med. 2012;87(4):411-8. doi:10.109…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44875/psn-pdf
    March 02, 2016 - "Teach-back" from a patient's perspective. March 2, 2016 Miller S, Lattanzio M, Cohen S. "Teach-back" from a patient's perspective. Nursing (Brux). 2016;46(2):63-4. doi:10.1097/01.NURSE.0000476249.18503.f5. https://psnet.ahrq.gov/issue/teach-back-patients-perspective The teach-back method, having patients repeat i…
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