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9821. Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue]. | PSNet
      psnet.ahrq.gov/issue/morphine-overdose-error-propagation-acute-pain-service-une-surdose-de-morphine-resultant-de
      January 13, 2016 - Commentary Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue]. Citation Text: Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant …

9822. Common Formats for Patient Safety Data Collection. | PSNet
      psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection
      October 08, 2024 - Press Release/Announcement Common Formats for Patient Safety Data Collection. Citation Text: Common Formats for Patient Safety Data Collection. Agency for Healthcare Research and Quality. Fed Register. Mar 6, 2024;89(45);15992. Copy Citation Save Save to your li…

9823. The next generation of doctors may be learning bad habits at teaching hospitals with many safety violations. | PSNet
      psnet.ahrq.gov/issue/next-generation-doctors-may-be-learning-bad-habits-teaching-hospitals-many-safety-violations
      June 28, 2023 - Newspaper/Magazine Article The next generation of doctors may be learning bad habits at teaching hospitals with many safety violations. Citation Text: The next generation of doctors may be learning bad habits at teaching hospitals with many safety violations. Blau M. STAT. April 20, 2018…

9824. Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a quasi-experimental study. | PSNet
      psnet.ahrq.gov/issue/assessment-potential-impact-reminder-system-reduction-diagnostic-errors-quasi-experimental
      April 19, 2011 - Study Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a quasi-experimental study. Citation Text: Ramnarayan P, Roberts GC, Coren M, et al. Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a qua…

9825. Using simulation training to improve perioperative patient safety. | PSNet
      psnet.ahrq.gov/issue/using-simulation-training-improve-perioperative-patient-safety
      August 20, 2018 - Study Using simulation training to improve perioperative patient safety. Citation Text: Mullen L, Byrd D. Using simulation training to improve perioperative patient safety. AORN J. 2013;97(4):419-27. doi:10.1016/j.aorn.2013.02.001. Copy Citation Format: DOI Google Scholar …

9826. When good doctors go bad: a systems problem. | PSNet
      psnet.ahrq.gov/issue/when-good-doctors-go-bad-systems-problem
      November 02, 2014 - Commentary When good doctors go bad: a systems problem. Citation Text: Leape L. When good doctors go bad: a systems problem. Ann Surg. 2006;244(5):649-652. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

9827. Patient safety: is it just another bandwagon? | PSNet
      psnet.ahrq.gov/issue/patient-safety-it-just-another-bandwagon
      June 12, 2013 - Commentary Patient safety: is it just another bandwagon? Citation Text: Storch JL. Patient safety: is it just another bandwagon? Nurs Leadersh (Tor Ont). 2005;18(2):39-55. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…

9828. Day passes for vulnerable patients of psychiatric hospitals can have dangerous, even fatal consequences. | PSNet
      psnet.ahrq.gov/issue/day-passes-vulnerable-patients-psychiatric-hospitals-can-have-dangerous-even-fatal
      October 29, 2014 - Newspaper/Magazine Article Day passes for vulnerable patients of psychiatric hospitals can have dangerous, even fatal consequences. Citation Text: Day passes for vulnerable patients of psychiatric hospitals can have dangerous, even fatal consequences. Woodruff E. Baltimore Sun. June 9, 2…

9829. Making checklists work: South Carolina's statewide experiment. | PSNet
      psnet.ahrq.gov/issue/making-checklists-work-south-carolinas-statewide-experiment
      April 01, 2015 - Newspaper/Magazine Article Making checklists work: South Carolina's statewide experiment. Citation Text: Rice S. MAKING CHECKLISTS WORK. Modern healthcare. 2016;46(4):14-6. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…

9830. Recognizing the ordinary as extraordinary: insight into the "way we work" to improve patient safety outcomes. | PSNet
      psnet.ahrq.gov/issue/recognizing-ordinary-extraordinary-insight-way-we-work-improve-patient-safety-outcomes
      December 12, 2012 - Commentary Recognizing the ordinary as extraordinary: insight into the "way we work" to improve patient safety outcomes. Citation Text: Henneman EA. Recognizing the Ordinary as Extraordinary: Insight Into the "Way We Work" to Improve Patient Safety Outcomes. Am J Crit Care. 2017;26(4):27…

9831. Toolkit 2. Using Nursing Home Antibiograms To Choose the Right Antibiotic (Concise Antibiogram Toolkit) | Agency for Healthcare Research and Quality
      www.ahrq.gov/nhguide/toolkits/help-clinicians-choose-the-right-antibiotic/toolkit2-concise-antibiogram-toolkit.html
      October 01, 2016 - Toolkit 2. Using Nursing Home Antibiograms To Choose the Right Antibiotic (Concise Antibiogram Toolkit) Toolkit Effectiveness When an antibiogram was implemented in nursing homes, results suggested that it had an effect on antibiotic prescribing. For example, Ciprofloxacin was prescribed 15% of the time versu…

9832. Among the elderly, many mental illnesses go undiagnosed. | PSNet
      psnet.ahrq.gov/issue/among-elderly-many-mental-illnesses-go-undiagnosed
      May 15, 2024 - Commentary Among the elderly, many mental illnesses go undiagnosed. Citation Text: Bor JS. Among the elderly, many mental illnesses go undiagnosed. Health Aff (Millwood). 2015;34(5):727-31. doi:10.1377/hlthaff.2015.0314. Copy Citation Format: DOI Google Scholar PubMed BibTe…

9833. Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS. | PSNet
      psnet.ahrq.gov/issue/unlocking-solutions-imaging-working-together-learn-failings-nhs
      October 07, 2020 - Book/Report Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS. Citation Text: Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS. Manchester, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016.  …

9834. ONC Health IT Certification Program: Enhanced Oversight and Accountability. | PSNet
      psnet.ahrq.gov/issue/onc-health-it-certification-program-enhanced-oversight-and-accountability
      June 29, 2016 - Government Resource ONC Health IT Certification Program: Enhanced Oversight and Accountability. Citation Text: ONC Health IT Certification Program: Enhanced Oversight and Accountability. Office of the National Coordinator for Health Information Technology; ONC; Health and Human Services;…

9835. Reducing Adverse Drug Events Related to Opioids Implementation Guide. | PSNet
      psnet.ahrq.gov/issue/reducing-adverse-drug-events-related-opioids-implementation-guide
      January 26, 2022 - Toolkit Reducing Adverse Drug Events Related to Opioids Implementation Guide. Citation Text: Reducing Adverse Drug Events Related to Opioids Implementation Guide. Frederickson TW. Gordon DB, De Pinto M, et al. Philadelphia, PA: Society of Hospital Medicine; 2015. Copy Citation …

9836. Antimicrobial stewardship and patient safety. | PSNet
      psnet.ahrq.gov/issue/antimicrobial-stewardship-and-patient-safety
      May 15, 2024 - Commentary Antimicrobial stewardship and patient safety. Citation Text: Zukowski CM. Antimicrobial Stewardship and Patient Safety. AORN J. 2016;104(4):354-356. doi:10.1016/j.aorn.2016.08.002. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XM…

9837. Bar coding for patient safety. | PSNet
      psnet.ahrq.gov/issue/bar-coding-patient-safety
      February 12, 2020 - Commentary Bar coding for patient safety. Citation Text: Wright AA, Katz IT. Bar coding for patient safety. N Engl J Med. 2005;353(4):329-31. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cit…

9838. Strategy 2: Communicating to Improve Quality | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/patients-families/engagingfamilies/strategy2/index.html
      December 01, 2017 - Strategy 2: Communicating to Improve Quality Research shows that when patients are engaged in their health care, it can lead to measurable improvements in safety and quality. To promote stronger engagement, Agency for Healthcare Research and Quality developed the Guide to Patient and Family Engagement in Hospit…

9839. Reducing medication prescribing errors in a teaching hospital. | PSNet
      psnet.ahrq.gov/issue/reducing-medication-prescribing-errors-teaching-hospital
      August 02, 2010 - Study Reducing medication prescribing errors in a teaching hospital. Citation Text: Garbutt J, Milligan PE, McNaughton C, et al. Reducing medication prescribing errors in a teaching hospital. Jt Comm J Qual Patient Saf. 2008;34(9):528-536. Copy Citation Format: Google Sch…

9840. 026-Assessing-Evc-Essential-One-Pager (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/026-assessing-evc-essential-one-pager.docx
      October 01, 2024 - When starting or improving an environmental cleaning (EVC) monitoring program, there are five essential steps to address, which are outlined below. This document focuses on the implementation of fluorescent gel (FG) monitoring, which is generally easier to use and implement, especially when starting a new monitoring pr…