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61. Safely practicing in a new environment: a qualitative study to inform physician onboarding practices. | PSNet
    psnet.ahrq.gov/issue/safely-practicing-new-environment-qualitative-study-inform-physician-onboarding-practices
    July 02, 2019 - Qualitative analysis found that three key findings: (1) physicians often receive little to no onboarding when starting

62. Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. | PSNet
    psnet.ahrq.gov/issue/closing-loop-guide-safer-ambulatory-referrals-ehr-era
    July 12, 2017 - The report delineates nine steps in the referral process, starting from the primary care provider ordering

63. ‘He thought what he was doing was good for people.’ Why is it so difficult to prevent unnecessary medical procedures in the U.S. health-care system? | PSNet
    psnet.ahrq.gov/issue/he-thought-what-he-was-doing-was-good-people-why-it-so-difficult-prevent-unnecessary-medical
    September 02, 2020 - But the media is starting to.

64. Nearly all hospital pharmacists say drug shortages are negatively impacting care; a third say impacts are ‘critical.’ | PSNet
    psnet.ahrq.gov/issue/nearly-all-hospital-pharmacists-say-drug-shortages-are-negatively-impacting-care-third-say
    September 15, 2021 - But the media is starting to.

65. Hidden Heparins: HIT Happens | PSNet
    psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
    March 27, 2024 - rarely occurs when warfarin is introduced in a patient with HIT and typically begins within days of starting … PTTs should be obtained 4 hours after starting the infusion and at least daily during treatment. … Nadir 10–19, or 30–50% platelet fall from baseline Nadir Timing of onset of platelet fall after starting … **Warfarin should not be started until platelet count has recovered (plt >100K); starting dose should

66. What Have We Learned About Safe Inpatient Handovers? | PSNet
    psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
    March 01, 2011 - Until then, the approaches described above provide a good starting point to guide medical centers in … We're starting to see studies examining how education can improve handoffs. … We're starting to understand that we need to risk-stratify handoffs and that not all handoffs are the … VA: We're starting to move into that realm. … Some of our newest work is starting to look at what a good listener is supposed to be doing during the

67. Risk factors for hospital admissions associated with adverse drug events. | PSNet
    psnet.ahrq.gov/issue/risk-factors-hospital-admissions-associated-adverse-drug-events
    October 18, 2018 - predictors associated with preventable adverse drug event admissions, such as the amount of time since starting

68. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/861838/psn-pdf
    January 31, 2024 - CEDAR provided eligible patients with automated calls at one and four months after starting one of the … requirements to be transferred to a live pharmacist because they reported a potential side effect since starting … Perhaps an easy starting point is targeting selected high-risk drugs and using the patient portal to

69. Five simple steps to avoid becoming a medical mystery. | PSNet
    psnet.ahrq.gov/issue/five-simple-steps-avoid-becoming-medical-mystery
    December 20, 2017 - But the media is starting to.

70. The burnout crisis in American medicine. | PSNet
    psnet.ahrq.gov/issue/burnout-crisis-american-medicine
    September 03, 2014 - But the media is starting to.

71. Doctors say patients who lie may put their health at risk. | PSNet
    psnet.ahrq.gov/issue/doctors-say-patients-who-lie-may-put-their-health-risk
    March 06, 2005 - But the media is starting to.

72. Rethinking hospital restraints. | PSNet
    psnet.ahrq.gov/issue/rethinking-hospital-restraints
    May 04, 2011 - But the media is starting to.

73. Paying the piper: investing in infrastructure for patient safety.  | PSNet
    psnet.ahrq.gov/issue/paying-piper-investing-infrastructure-patient-safety
    July 01, 2017 - Peter Pronovost and colleagues describe the sequential investments made in human capital starting from

74. Preventable deaths: who, how often, and why? | PSNet
    psnet.ahrq.gov/issue/preventable-deaths-who-how-often-and-why
    February 22, 2011 - The study involved four phases, starting with a sampling method in which 182 deaths from 12 hospitals

75. The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications | PSNet
    psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
    July 23, 2024 - Resources Used and Skills Needed The consortium recommends starting the initiative by establishing … Subsequently, the collaborative rolled out a two-tiered approach to improving appropriate PICC use starting … baseline data collection and benchmarking Resources Used and Skills Needed The consortium recommends starting … Using tiers of targeted interventions starting with a focus on multiple outcomes (Tier 1), and then narrowing

76. Understanding and responding when things go wrong: key principles for primary care educators. | PSNet
    psnet.ahrq.gov/issue/understanding-and-responding-when-things-go-wrong-key-principles-primary-care-educators
    January 23, 2017 - They argue that human error should be the starting point rather than a root cause in any error analysis

77. Engaging patients in medication reconciliation via a patient portal following hospital discharge. | PSNet
    psnet.ahrq.gov/issue/engaging-patients-medication-reconciliation-patient-portal-following-hospital-discharge
    February 03, 2011 - outpatient medication reconciliation and secure messaging to identify adverse drug events after starting

78. Interorganizational health information exchange-related patient safety incidents: a descriptive register-based qualitative study. | PSNet
    psnet.ahrq.gov/issue/interorganizational-health-information-exchange-related-patient-safety-incidents-descriptive
    November 10, 2021 - September 25, 2024 Organizational learning starting points and presuppositions: a case

79. Impact of staff turnover during cardiac surgical procedures. | PSNet
    psnet.ahrq.gov/issue/impact-staff-turnover-during-cardiac-surgical-procedures
    November 06, 2019 - RIS Download Citation Related Resources From the Same Author(s) Starting

80. An analysis of electronic health record–related patient safety incidents. | PSNet
    psnet.ahrq.gov/issue/analysis-electronic-health-record-related-patient-safety-incidents
    August 19, 2020 - December 29, 2014 Organizational learning starting points and presuppositions: a case