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Showing results for "the change teams".

  1. Frequent diagnostic errors in cardiac PET/CT due to misregistration of CT attenuation and emission PET images: a definitive analysis of causes, consequences, and corrections. | PSNet

    psnet.ahrq.gov/issue/frequent-diagnostic-errors-cardiac-petct-due-misregistration-ct-attenuation-and-emission-pet
    December 22, 2018 - View more articles from the same authors. … The authors discuss methods for avoiding such errors. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … December 22, 2018 WebM&M Cases Crossing the Line … the burden of adverse events: a systematic review of second victim support resources.

  2. Automatic detection of omissions in medication lists. | PSNet

    psnet.ahrq.gov/issue/automatic-detection-omissions-medication-lists
    December 31, 2014 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … September 9, 2013 The top patient safety strategies that can be encouraged for adoption … June 14, 2023 Advancing the science of patient safety. … October 4, 2023 Exploring the impact of safety culture on incident reporting: lessons

  3. Medication injection safety knowledge and practices among anesthesiologists: New York State, 2011. | PSNet

    psnet.ahrq.gov/issue/medication-injection-safety-knowledge-and-practices-among-anesthesiologists-new-york-state
    August 25, 2021 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … Effect of an emergency department process improvement package on suicide prevention: the … January 25, 2022 The nature of reported safety events related to care coordination in … the operating room setting in a tertiary academic center.

  4. Survey of medication documentation at hospital discharge: implications for patient safety and continuity of care. | PSNet

    psnet.ahrq.gov/issue/survey-medication-documentation-hospital-discharge-implications-patient-safety-and-continuity
    March 02, 2011 - View more articles from the same authors. … The most frequent error was inadvertent omission of a medication. … November 2, 2010 The design of the SAFE or SORRY? … program for the prevention of adverse events. … November 16, 2022 Improving handoffs in the emergency department.

  5. Critical care transition programs and the risk of readmission or death after discharge from an ICU: a systematic review and meta-analysis. | PSNet

    psnet.ahrq.gov/issue/critical-care-transition-programs-and-risk-readmission-or-death-after-discharge-icu
    October 13, 2018 - Review Critical care transition programs and the risk of readmission or death after … Critical care transition programs and the risk of readmission or death after discharge from an ICU: a … View more articles from the same authors. … the intensive care unit: a multicenter population-based cohort study. … March 20, 2015 Physician staffing models and patient safety in the ICU.

  6. Systematic review of malpractice litigation in the diagnosis and treatment of acute stroke | PSNet

    psnet.ahrq.gov/issue/systematic-review-malpractice-litigation-diagnosis-and-treatment-acute-stroke
    October 19, 2022 - Journal Article Systematic review of malpractice litigation in the diagnosis and … Systematic Review of Malpractice Litigation in the Diagnosis and Treatment of Acute Stroke. … View more articles from the same authors. … Systematic Review of Malpractice Litigation in the Diagnosis and Treatment of Acute Stroke. … June 17, 2020 Call me Ishmael: addressing the white whale of team communication in the

  7. People are more error-prone after committing an error. | PSNet

    psnet.ahrq.gov/issue/people-are-more-error-prone-after-committing-error
    June 29, 2011 - View more articles from the same authors. … This article explores the concept of post-error slowing. … September 23, 2020 The surgeon as the second victim? … Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) study. … September 11, 2024 What's the harm?

  8. Peer support in anesthesia: turning war stories into wellness. | PSNet

    psnet.ahrq.gov/issue/peer-support-anesthesia-turning-war-stories-wellness
    July 13, 2010 - View more articles from the same authors. … The authors emphasize the value of overarching policy changes to provide the foundation needed for … for the quality of care of patients with acute myocardial infarction: results of the Emergency Department … March 14, 2018 The global burden of diagnostic errors in primary care. … June 14, 2017 Assessing the perceived level of institutional support for the second victim

  9. Medical errors and consequent adverse events in critically ill surgical patients in a tertiary care teaching hospital in Delhi. | PSNet

    psnet.ahrq.gov/issue/medical-errors-and-consequent-adverse-events-critically-ill-surgical-patients-tertiary-care
    December 22, 2010 - View more articles from the same authors. … analyzed nearly 600 consecutive patient cases with a structured case review tool to highlight what the … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … March 2, 2011 Comparison of the clinical diagnosis and subsequent autopsy findings in … January 6, 2010 Using Medical Emergency Teams to detect preventable adverse events.

  10. Application of root cause analysis on malpractice claim files related to diagnostic failures. | PSNet

    psnet.ahrq.gov/issue/application-root-cause-analysis-malpractice-claim-files-related-diagnostic-failures
    March 01, 2011 - View more articles from the same authors. … This study applied root cause analysis to cases of diagnostic failure , and discusses the feasibility … March 1, 2011 Is culture associated with patient safety in the emergency department? … observation tool to quantify the use of non-technical skills in healthcare. … July 10, 2013 The relationship between patient safety culture and the implementation

  11. Problems with medical devices may be severely under-reported. | PSNet

    psnet.ahrq.gov/issue/problems-medical-devices-may-be-severely-under-reported
    November 16, 2022 - View more articles from the same authors. … The authors surveyed 1000 Ontario nurses to determine awareness of the Health Canada Medical Device Problem … Although 72.5% of nurses polled had encountered problems with medical devices, 94.2% were unaware of the … A case study of radical change toward patient safety. … The Report of the Independent Medicines and Medical Devices Safety Review.

  12. Making use of mortality data to improve quality and safety in general practice: a review of current approaches. | PSNet

    psnet.ahrq.gov/issue/making-use-mortality-data-improve-quality-and-safety-general-practice-review-current
    November 17, 2010 - View more articles from the same authors. … The investigators analyzed the literature and found that mortality data are not systematically used to … March 2, 2011 The Lancet Commission on lessons for the future from the COVID-19 pandemic … health care teams. … to a solution: a systematic review of the literature.

  13. The safety of emergency care systems: results of a survey of clinicians in 65 US emergency departments. | PSNet

    psnet.ahrq.gov/issue/safety-emergency-care-systems-results-survey-clinicians-65-us-emergency-departments
    June 07, 2008 - Study The safety of emergency care systems: results of a survey of clinicians in … View more articles from the same authors. … This study's findings raise concern about the current state of emergency care, most notably the presence … November 8, 2013 Teams under pressure in the emergency department: an interview study … March 23, 2012 The association between a prolonged stay in the emergency department and

  14. Privacy Policy | PSNet

    psnet.ahrq.gov/Information/Privacy
    May 23, 2025 - The site is produced by an editorial team at the University of California, Davis under a contract from … All communications to the Web site mailbox are removed from the server. … users, we employ software programs to monitor traffic to identify unauthorized attempts to upload or change … The inclusion of external hyperlinks does not constitute endorsement by HHS or AHRQ of the linked Web … The Agency does not exercise any control over the content on external sites.

  15. Prevalence and patterns of potentially avoidable hospitalizations in the US long-term care setting. | PSNet

    psnet.ahrq.gov/issue/prevalence-and-patterns-potentially-avoidable-hospitalizations-us-long-term-care-setting
    August 04, 2021 - Study Prevalence and patterns of potentially avoidable hospitalizations in the US … Prevalence and patterns of potentially avoidable hospitalizations in the US long-term care setting. … View more articles from the same authors. Safety problems are common in nursing homes . … Prevalence and patterns of potentially avoidable hospitalizations in the US long-term care setting. … June 16, 2011 Safety culture in cardiac surgical teams: data from five programs and national

  16. Reframing the morbidity and mortality conference: the impact of a just culture. | PSNet

    psnet.ahrq.gov/issue/reframing-morbidity-and-mortality-conference-impact-just-culture
    November 15, 2018 - Review Reframing the morbidity and mortality conference: the impact of a just culture … Reframing the morbidity and mortality conference: the impact of a just culture. … View more articles from the same authors. … Reframing the morbidity and mortality conference: the impact of a just culture. … February 9, 2022 The Lancet Commission on lessons for the future from the COVID-19 pandemic

  17. A clinical case of electronic health record drug alert fatigue: consequences for patient outcome. | PSNet

    psnet.ahrq.gov/issue/clinical-case-electronic-health-record-drug-alert-fatigue-consequences-patient-outcome
    August 02, 2023 - View more articles from the same authors. … hospital made in its medication allergy alert system in response to the event. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … November 16, 2022 Improving communication with primary care physicians at the time of … March 25, 2017 Performance of the Global Assessment of Pediatric Patient Safety (GAPPS

  18. Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care. | PSNet

    psnet.ahrq.gov/issue/alliance-innovation-maternal-health-consensus-bundle-sepsis-obstetric-care
    August 21, 2024 - View more articles from the same authors. … Developed by the Alliance for Innovation on Maternal Health (AIM), this patient safety bundle provides … guidance for healthcare teams to improve the prevention, recognition, and treatment of infections and … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … November 13, 2024 Optimizing Pediatric Patient Safety in the Emergency Care Setting.

  19. SBAR: electronic handoff tool for noncomplicated procedural patients. | PSNet

    psnet.ahrq.gov/issue/sbar-electronic-handoff-tool-noncomplicated-procedural-patients
    October 19, 2022 - View more articles from the same authors. … This study reports on the use of SBAR to improve handoffs of postprocedural patients. … Same Author(s) Optimizing Pediatric Patient Safety in the Emergency Care Setting. … August 16, 2017 Crowding in the Emergency Department: Challenges for the Care of Children … January 3, 2017 Improving the quality of the surgical morbidity and mortality conference

  20. Could it be done safely? Pharmacists views on safety and clinical outcomes from the introduction of an advanced role for technicians. | PSNet

    psnet.ahrq.gov/issue/could-it-be-done-safely-pharmacists-views-safety-and-clinical-outcomes-introduction-advanced
    October 22, 2014 - Pharmacists views on safety and clinical outcomes from the introduction of an advanced role for technicians … View more articles from the same authors. … This work adds to the literature supporting the use of teams to improve patient safety. … October 22, 2014 Implementation of the safety huddle. … Healthcare practitioners' views of the effectiveness of incident reporting.
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