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9841. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851927/psn-pdf
      August 02, 2023 - Perioperative Handoffs. August 2, 2023 Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434. https://psnet.ahrq.gov/issue/perioperative-handoffs Handoffs occur several times during a surgical procedure, increasing the risk of communication mistakes and misunderstandings. This special…

9842. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50874/psn-pdf
      February 05, 2020 - Checking In on the Checklist. February 5, 2020 Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020. https://psnet.ahrq.gov/issue/checking-checklist Checklists are integrated into error reduction strategies and healthcare team communication efforts worldwide but implementation and impact of the tool varies …

9843. Invitation Letter Sample for Small Practices | Agency for Healthcare Research and Quality
      www.ahrq.gov/evidencenow/projects/urinary/resources/invitation-letter-sample.html
      February 01, 2019 - Back to MUI Resources Invitation Letter Sample for Small Practices Resource Document available on the AHRQ website (PDF, 157 KB) Summary This resource is an example of a recruitment invitation letter directed towards small primary care practices that outlines benefits of prac…

9844. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41668/psn-pdf
      December 21, 2014 - A surgical simulation curriculum for senior medical students based on TeamSTEPPS. December 21, 2014 Meier AH, Boehler ML, McDowell CM, et al. A surgical simulation curriculum for senior medical students based on TeamSTEPPS. Arch Surg. 2012;147(8):761-6. doi:10.1001/archsurg.2012.1340. https://psnet.ahrq.gov/issue/…

9845. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846765/psn-pdf
      March 29, 2023 - Addressing Medical Gaslighting to Improve Maternal Health—Together. March 29, 2023 Oregon Patient Safety Commission: 2023. https://psnet.ahrq.gov/issue/addressing-medical-gaslighting-improve-maternal-health-together Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit …

9846. 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…

9847. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40885/psn-pdf
      November 26, 2014 - Hospital do-not-resuscitate orders: why they have failed and how to fix them. November 26, 2014 Yuen JK, Reid C, Fetters MD. Hospital do-not-resuscitate orders: why they have failed and how to fix them. J Gen Intern Med. 2011;26(7):791-7. doi:10.1007/s11606-011-1632-x. https://psnet.ahrq.gov/issue/hospital-do-not-…

9848. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39262/psn-pdf
      March 04, 2011 - Unintended errors with EHR-based result management: a case series. March 4, 2011 Yackel TR, Embi P. Unintended errors with EHR-based result management: a case series. J Am Med Inform Assoc. 2010;17(1):104-7. doi:10.1197/jamia.M3294. https://psnet.ahrq.gov/issue/unintended-errors-ehr-based-result-management-case-se…

9849. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47049/psn-pdf
      July 10, 2019 - Injectable Opioid Shortages: Suggestions for Management and Conservation. July 10, 2019 University of Utah Drug Information Service; ASHP; American Society of Health-System Pharmacists. https://psnet.ahrq.gov/issue/injectable-opioid-shortages-suggestions-management-and-conservation Efforts to limit the availabilit…

9850. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853627/psn-pdf
      September 20, 2023 - Understanding And Addressing Pre-Hospital Diagnostic Delays. September 20, 2023 Health Affairs Forefront; May-September 2023. https://psnet.ahrq.gov/issue/understanding-and-addressing-pre-hospital-diagnostic-delays Diagnostic delays stem from both human and process failures. This series of articles examines how s…

9851. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45649/psn-pdf
      November 30, 2016 - Displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy … Displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy

9852. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42918/psn-pdf
      February 05, 2014 - disclosure of medical errors has been described as both a great idea and an impractical risk management strategy … full-disclosure-and-apology-idea-whose-time-has-come https://psnet.ahrq.gov/issue/disclosure-medical-injury-patients-improbable-risk-management-strategy

9853. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46575/psn-pdf
      December 13, 2017 - economic-evaluation-pharmacist-led-medication-reviews-residential-aged- care-facilities Pharmacist oversight of medication prescribing is an established safety strategy … inappropriate polypharmacy in aged care facilities and the cost- effectiveness of this risk management strategy

9854. Assessing and monitoring override medications in automated dispensing devices. | PSNet
      psnet.ahrq.gov/issue/assessing-and-monitoring-override-medications-automated-dispensing-devices
      May 06, 2009 - May 6, 2009 Designing a strategy to promote safe, innovative off-label use of medications … September 29, 2010 Developing a medication patient safety program — infrastructure and strategy … December 30, 2014 A randomized trial of a multifactorial strategy to prevent serious

9855. Team-training in healthcare: a narrative synthesis of the literature. | PSNet
      psnet.ahrq.gov/issue/team-training-healthcare-narrative-synthesis-literature
      July 02, 2014 - Related Resources From the Same Author(s) Promoting a culture of safety as a patient safety strategy … July 2, 2014 Rapid response systems as a patient safety strategy: a systematic review … October 10, 2017 Towards high-reliability organising in healthcare: a strategy for building

9856. Health IT Patient Safety Action and Surveillance Plan. | PSNet
      psnet.ahrq.gov/issue/health-it-patient-safety-action-and-surveillance-plan
      December 18, 2013 - May 13, 2015 Strategy on Reducing Regulatory and Administrative Burden Relating to the … February 20, 2019 FDASIA Health IT Report: Proposed Strategy and Recommendations for … July 5, 2016 View More Related Resources Strategy on Reducing Regulatory

9857. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45244/psn-pdf
      August 01, 2016 - exploring how sleep deprivation affects clinician performance and the impact of work hour limits as a strategy … common-program-requirements-learning-and-working-environment-duty-hours https://psnet.ahrq.gov/issue/handoffs-era-duty-hours-reform-focused-review-and-strategy-address-changes-accreditation

9858. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47582/psn-pdf
      December 12, 2018 - data from chart review and taking ulcer severity into account may yield a more meaningful measurement strategy … success-hospital-acquired-pressure-ulcer-prevention-tale-two-data-sets https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review

9859. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36814/psn-pdf
      March 28, 2011 - paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy … paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy

9860. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45277/psn-pdf
      July 01, 2017 - really-possible Crew resource management (CRM), a type of team training, is a prime example of an aviation strategy … They propose more widespread implementation of CRM as a strategy to enhance safety culture.