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Reversing the rise in maternal mortality. | PSNet

psnet.ahrq.gov/issue/reversing-rise-maternal-mortality

January 18, 2017 - Commentary Reversing the rise in maternal mortality. … Reversing The Rise In Maternal Mortality. … View more articles from the same authors. … Reversing The Rise In Maternal Mortality. … December 9, 2015 The Report of the Morecambe Bay Investigation.

Overarching goals: a strategy for improving healthcare quality and safety? | PSNet

psnet.ahrq.gov/issue/overarching-goals-strategy-improving-healthcare-quality-and-safety

September 24, 2018 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … September 20, 2011 Advancing the science of patient safety. … April 17, 2018 Applying ethnography to the study of context in healthcare quality and … Perspective What We've Learned About Leveraging Leadership and Culture to Affect Change

Society for Maternal-Fetal Medicine Special Statement: a maternal transport briefing form and checklist. | PSNet

psnet.ahrq.gov/issue/society-maternal-fetal-medicine-special-statement-maternal-transport-briefing-form-and

September 08, 2021 - View more articles from the same authors. … This guidance explores the use of a checklist to standardize team communication and coordination … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … December 16, 2020 Field Guide to Collaborative Care: Implementing the Future of Health … December 9, 2014 Diagnosis: Interpreting the Shadows.

Relationship between systems-level factors and hand hygiene adherence. | PSNet

psnet.ahrq.gov/issue/relationship-between-systems-level-factors-and-hand-hygiene-adherence

September 28, 2011 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … hospitalized patients and risk for Clostridium difficile infection in subsequent patients who occupy the … November 11, 2015 Sepsis: recognizing the next event. … June 29, 2011 Achieving quality improvement in the nursing home: influence of nursing

Cognitive versus technical debriefing after simulation training. | PSNet

psnet.ahrq.gov/issue/cognitive-versus-technical-debriefing-after-simulation-training

September 12, 2011 - View more articles from the same authors. … subject matter or a cognitive debriefing on the failure. … They found that the technical debriefing was received slightly better by residents. … over the past decade of duty hour changes. … October 19, 2011 Assessment of the potential impact of a reminder system on the reduction

Quality improvement initiative to reduce serious safety events and improve patient safety culture. | PSNet

psnet.ahrq.gov/issue/quality-improvement-initiative-reduce-serious-safety-events-and-improve-patient-safety

July 24, 2017 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … December 18, 2014 Using a network organisational architecture to support the development … November 21, 2016 Sustaining and spreading the reduction of adverse drug events in a … April 11, 2011 The Preventable Harm Index: an effective motivator to facilitate the drive

Measurement and Monitoring of Safety Framework (MMSF): learning from its implementation in Canada. | PSNet

psnet.ahrq.gov/issue/measurement-and-monitoring-safety-framework-mmsf-learning-its-implementation-canada

September 24, 2018 - View more articles from the same authors. … 2018 Safety measurement and monitoring in healthcare: a framework to guide clinical teams … beneath the surface? … the know-do gap. … past and (re)imagining the future.

Hospital doctors' workflow interruptions and activities: an observation study. | PSNet

psnet.ahrq.gov/issue/hospital-doctors-workflow-interruptions-and-activities-observation-study

March 06, 2013 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … May 21, 2009 The randomized AMBORA trial: impact of pharmacological/pharmaceutical care … complexity of the discharge process. … September 26, 2016 Shift change handovers and subsequent interruptions: potential impacts

Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician. | PSNet

psnet.ahrq.gov/issue/getting-message-quality-improvement-initiative-reduce-pages-sent-wrong-physician

April 30, 2014 - to the wrong physician. … Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician. … Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician. … January 20, 2016 Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change … A review of the literature.

Perspectives in quality: designing the WHO Surgical Safety Checklist. | PSNet

psnet.ahrq.gov/issue/perspectives-quality-designing-who-surgical-safety-checklist

September 20, 2011 - Perspectives in quality: designing the WHO Surgical Safety Checklist. … View more articles from the same authors. … Perspectives in quality: designing the WHO Surgical Safety Checklist. … September 21, 2023 Information transfer in multidisciplinary operating room teams: a … November 18, 2013 Wise before the event.

Intolerance of error and culture of blame drive medical excess. | PSNet

psnet.ahrq.gov/issue/intolerance-error-and-culture-blame-drive-medical-excess

March 24, 2017 - View more articles from the same authors. … in order to achieve behavior change. … , electronic adverse drug event triggers designed for the outpatient setting. … March 2, 2022 The paradoxes of defensive medicine. … August 3, 2020 The Sorry Works! Coalition: making the case for full disclosure.

Interruption handling strategies during paediatric medication administration. | PSNet

psnet.ahrq.gov/issue/interruption-handling-strategies-during-paediatric-medication-administration

July 27, 2018 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … Association of patient and family reports of hospital safety climate with language proficiency in the … June 29, 2022 The patient handoff: a comprehensive curricular blueprint for resident … September 26, 2016 Safety as a criterion for quality: The Critical Nursing Situation

Patient safety: disclosure of medical errors and risk mitigation. | PSNet

psnet.ahrq.gov/issue/patient-safety-disclosure-medical-errors-and-risk-mitigation

June 07, 2017 - View more articles from the same authors. … This commentary describes the experiences of two health care systems that have implemented approaches … Same Author(s) Investigating the causes of adverse events. … March 16, 2016 Natural history of retained surgical items supports the need for team … December 6, 2023 Transparency, public reporting, and a culture of change to quality and

Approaches to decreasing medication and other care errors in the ICU. | PSNet

psnet.ahrq.gov/issue/approaches-decreasing-medication-and-other-care-errors-icu

September 30, 2010 - Approaches to decreasing medication and other care errors in the ICU. … View more articles from the same authors. … View More Related Resources Emergency department monitor alarms rarely change … September 16, 2020 Sound the alarm. … September 25, 2013 Patient monitoring alarms in the ICU and in the operating room.

Increasing physician reporting of diagnostic learning opportunities. | PSNet

psnet.ahrq.gov/issue/increasing-physician-reporting-diagnostic-learning-opportunities

March 23, 2022 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … March 23, 2022 Declaring uncertainty: using quality improvement methods to change the … October 20, 2021 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … December 19, 2018 What is the measure of a safe hospital?

Iatrogenic psychological harm. | PSNet

psnet.ahrq.gov/issue/iatrogenic-psychological-harm

February 28, 2024 - View more articles from the same authors. … July 21, 2017 Safety incidents in the primary care office setting. … hold the profession to account? … September 26, 2018 Challenging hierarchy in healthcare teams--ways to flatten gradients … beneath the surface?

Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. | PSNet

psnet.ahrq.gov/issue/medication-reconciliation-acute-care-ensuring-accurate-drug-regimen-admission-and-discharge

October 28, 2020 - View more articles from the same authors. … , design processes for use, and then audit the forms after put into practice. … November 23, 2016 The Medication Manager: results of a medication at the bedside pilot … June 16, 2019 The problem with medication reconciliation. … good, the bad, and the improvements.

The second victim: a contested term? | PSNet

psnet.ahrq.gov/issue/second-victim-contested-term

December 08, 2021 - The second victim: a contested term? … use of term ‘second victim’ can be seen as insensitive to the patient and can erode the professional … The second victim: a contested term? … April 7, 2021 Toward the development of the perfect medical team: critical components … February 15, 2023 Toward constructive change after making a medical error: recovery from

Time to sign off on signout. | PSNet

psnet.ahrq.gov/issue/time-sign-signout

March 11, 2011 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … February 8, 2017 The Veterans Affairs shift change physician-to-physician handoff project … March 4, 2011 Utilizing information technology to mitigate the handoff risks caused by … July 1, 2009 View More See More About The Topic Hospitals Physicians

Development and implementation of a pediatric patient safety program. | PSNet

psnet.ahrq.gov/issue/development-and-implementation-pediatric-patient-safety-program

September 27, 2010 - View more articles from the same authors. … , including the tools and resources that supported that work. … July 19, 2023 Handoffs in the era of duty hours reform: a focused review and strategy … May 11, 2011 Safety huddles in the PACU: when a patient self-medicates. … November 24, 2010 Findings of the first consensus conference on medical emergency teams

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