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221. An Inadvertent Bolus of Norepinephrine. | PSNet
     psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
     December 04, 2016 - port closest to the patient, unless contraindicated or inaccessible for use, such as during a sterile procedure … Vasoplegia after cardiovascular procedures—pathophysiology and targeted therapy. … Errors in the administration of intravenous medications in hospital and the role of correct procedures … Errors and discrepancies in the administration of intravenous infusions: a mixed-methods multihospital … Furniss D, Back J, Blandford A.

222. Suicidal Ideation in the Family Medicine Clinic | PSNet
     psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
     October 01, 2007 - She was brought back to the emergency department and ultimately admitted to an inpatient psychiatry unit … a supportive manner.( 8 ) Longer trainings, such as Mental Health First Aid, are also available and teach … Another best practice is counseling patients specifically on lethal means, methods for suicide with

223. What Do We Know About Emergency Department Safety? | PSNet
     psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
     June 01, 2010 - During high-risk procedures, providers must be allowed to focus on the procedure without interruptions … (iv) ED systems for teamwork and handoffs as well as guidelines for procedures and checklists should … Risks of complications by attending physicians after performing nighttime procedures. … [go to PubMed] Table Back to Top Table. Model of Patient Safety. … That's in contrast to a slower analytical, deductive method that's much more precise and often yields

224. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness | PSNet
     psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
     February 01, 2014 - Methods Inf Med. 2011;50:447-453. [go to PubMed] 2. Relihan E, O'Brien V, O'Hara S, Silke B. … You can get back into the task. … They teach us a lot about the sorts of systems we can eventually put in place to minimize distraction … that the person using your system might be distracted, turn away to do something else, and then come back … Of course the person answered the text message and went back and forgot to order the medicine and it

225. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49531/psn-pdf
     March 01, 2007 - answer, although the mistake would most likely be attributed to an unexplainable lapse in following procedures … To prevent unintentional unsafe acts—slips, lapses, mistakes, or procedure violations—the contributory … Make it easy to report and provide several different reporting methods.

226. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60865/psn-pdf
     August 31, 2020 - KH: Let’s go back to a couple of points you have made that I’d like to highlight. … KH: That idea really resonates - bringing together the culture and person and family engagement as methods

227. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866055/psn-pdf
     May 29, 2024 - Elements include verification and resolution of incorrect counts; a brief summary of the procedure and … Visual counter uses a white board that includes the patient identifiers and procedure details. … After they determined a simple plan for providers to follow in highly complex procedures, they knew … To sustain the gains from this campaign, Ascension is launching a “We Got Your Back” cultural campaign … Auditors review at least 20 operating room procedures per month.

228. In Conversation with...James L. Reinertsen, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
     August 01, 2007 - learned that, rather than just fixing things for our practice or the guy down the hall, with the right methods … wonderful stuff we just did," they'd hear—"A patient lost their hand in a farm accident and we put it back … If I, as CEO, can look them in the eye and say, the board is expecting us to come back in 3 months with … delays because you have to send it out to get all the data from whoever has to vet the stuff and get it back … targets are not met, they expect corrective action and carefully follow progress until the situation is back

229. The PeaceHealth Governance Journey in Support of Quality and Safety | PSNet
     psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
     August 01, 2007 - targets are not met, they expect corrective action and carefully follow progress until the situation is back … learned that, rather than just fixing things for our practice or the guy down the hall, with the right methods … wonderful stuff we just did," they'd hear—"A patient lost their hand in a farm accident and we put it back … If I, as CEO, can look them in the eye and say, the board is expecting us to come back in 3 months with … delays because you have to send it out to get all the data from whoever has to vet the stuff and get it back

230. Patient Safety in the United Kingdom: Evolution and Progress | PSNet
     psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
     May 01, 2007 - Systematic data collection of the hazards of health care can be traced back at least to the time of Florence … Charles Vincent, PhD Professor of Clinical Safety Research, Imperial College London References Back … 1950s and 1960s, it had all been about technical factors: the design of aircraft, the development of procedures … structure, and what seems to be invariable across national boundaries, organizational systems, and payment methods … That's where we can go back to the lessons of the airline industry.

231. Critical Echocardiogram Result Lost to Follow-up | PSNet
     psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
     July 31, 2023 - number of handoffs, which has been associated with more medical errors. 10 As a result, a structured method … draw attention to the vegetation finding in this case earlier after patient discharge and transfer back … Another method that may improve effective communication incorporates elements of CLC whereby an alert

232. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet
     psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
     February 26, 2025 - If that is not part of this organization, we could put that RCA back on the shelf and not look at it … Jessica Behrhorst:  When we teach RCA 2 , we stress that it is a toolkit, not just one tool. … I often think back to my early career. … Several years back, RCA 2 got approval from The Joint Commission. … For these reasons, the RCA method is supported by leading accrediting and federal agencies as a way

233. The Evolution of Root Cause Analysis | PSNet
     psnet.ahrq.gov/perspective/evolution-root-cause-analysis
     February 26, 2025 - For these reasons, the RCA method is supported by leading accrediting and federal agencies as a way … If that is not part of this organization, we could put that RCA back on the shelf and not look at it … Jessica Behrhorst:  When we teach RCA 2 , we stress that it is a toolkit, not just one tool. … I often think back to my early career. … Several years back, RCA 2 got approval from The Joint Commission.

234. Improving Diagnostic Safety and Quality | PSNet
     psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
     January 31, 2024 - Recognition of the multifactorial contributors to diagnostic safety spans back almost 20 years with Dr … work on diagnostic error in 2005, which includes an identification of systemic problems with policy, procedures … Recently, researchers and clinicians have debated methods for calculating error rates. … Methods to Improve Diagnostic Safety Because misdiagnosis arises from complex factors, reducing misdiagnosis

235. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/848107/psn-pdf
     April 26, 2023 - Recognition of the multifactorial contributors to diagnostic safety spans back almost 20 years with … work on diagnostic error in 2005, which includes an identification of systemic problems with policy, procedures … Recently, researchers and clinicians have debated methods for calculating error rates. … Methods to Improve Diagnostic Safety Because misdiagnosis arises from complex factors, reducing misdiagnosis

236. Failure to Report | PSNet
     psnet.ahrq.gov/web-mm/failure-report
     July 01, 2008 - answer, although the mistake would most likely be attributed to an unexplainable lapse in following procedures … To prevent unintentional unsafe acts—slips, lapses, mistakes, or procedure violations—the contributory … Make it easy to report and provide several different reporting methods. … October 27, 2010 Procedures should promote patient safety.

237. In Conversation with...Sir Liam Donaldson, MD, MSc | PSNet
     psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
     May 01, 2007 - 1950s and 1960s, it had all been about technical factors: the design of aircraft, the development of procedures … structure, and what seems to be invariable across national boundaries, organizational systems, and payment methods … That's where we can go back to the lessons of the airline industry. … Systematic data collection of the hazards of health care can be traced back at least to the time of Florence … Charles Vincent, PhD Professor of Clinical Safety Research, Imperial College London References Back

238. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please | PSNet
     psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
     September 01, 2011 - For measuring the actual incidence of safety events, other detection methods are more sensitive, including … errors, are currently addressed through morbidity and mortality conferences and hospital credentialing procedures … The actions that hospital leaders take in response to reports teach providers whether the time and risks … The VA has done a very good job with getting back to the reporter. … about what makes a good incident reporting system, it sounds like obviously a very strong follow-up procedure

239. In Conversation With…Kaveh G. Shojania, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
     September 01, 2011 - The VA has done a very good job with getting back to the reporter. … about what makes a good incident reporting system, it sounds like obviously a very strong follow-up procedure … For measuring the actual incidence of safety events, other detection methods are more sensitive, including … errors, are currently addressed through morbidity and mortality conferences and hospital credentialing procedures … The actions that hospital leaders take in response to reports teach providers whether the time and risks

240. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49651/psn-pdf
     May 01, 2012 - Emerging Handoff Curricula Although numerous curricula and instructional methods have been developed … references https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references A common way to teach … to evaluate receivers on use of active listening behaviors, such as interactive questioning, read-back