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8621. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49848/psn-pdf
      January 01, 2019 - A specific communication tool with prompts and a delineated chain of command to be followed during emergencies

8622. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49440/psn-pdf
      March 01, 2004 - received very little attention in the patient safety literature, concerns the role of the autopsy as a tool

8623. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846770/psn-pdf
      March 29, 2023 - Perforations – a complication of esophageal endoscopy Endoscopy is an important tool for both diagnostic

8624. Discharge Against Medical Advice | PSNet
      psnet.ahrq.gov/web-mm/discharge-against-medical-advice
      July 01, 2017 - Acceptability and feasibility of the Leapfrog computerized physician order entry evaluation tool

8625. The Wrong Channel | PSNet
      psnet.ahrq.gov/web-mm/wrong-channel
      February 01, 2003 - Human factors engineering: a tool for medical device evaluation in hospital procurement decision-making

8626. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules | PSNet
      psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
      March 25, 2020 - Evaluation of Anesthesiology Residents' Supervision Skills: A Tool to Assess Transition Towards Independent

8627. The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis | PSNet
      psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
      February 26, 2025 - Streamlining care in crisis: rapid creation and implementation of a digital support tool for COVID-19

8628. Two Wrongs Don't Make a Right (Kidney) | PSNet
      psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
      April 01, 2010 - As this case has demonstrated, the Universal Protocol can be a useful tool in preventing wrong-site surgery

8629. Autopsy Revelation | PSNet
      psnet.ahrq.gov/web-mm/autopsy-revelation
      December 01, 2007 - received very little attention in the patient safety literature, concerns the role of the autopsy as a tool

8630. Methicillin-Resistant Staphylococcus aureus | PSNet
      psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
      June 24, 2010 - Perspective The Physical Environment: An Often Unconsidered Patient Safety Tool

8631. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865778/psn-pdf
      May 29, 2024 - formation (95% CI, 12%-92%) with ultrasound guidance.5 Ultrasound has also been shown to be a valuable tool

8632. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49455/psn-pdf
      July 01, 2004 - references https://psnet.ahrq.gov//#references The Limitations of CT Scanning CT is a powerful diagnostic tool

8633. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49799/psn-pdf
      July 01, 2017 - results after hospital discharge: improving patient safety through an automated medical informatics tool

8634. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-469
      December 31, 2024 - The authors use their experience developing a machine learning-based clinical decision support tool to

8635. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation | PSNet
      psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
      November 25, 2020 - WebM&M Cases Failed Interpretation of Screening Tool

8636. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33569/psn-pdf
      June 15, 2024 - Readmissions and Adverse Events After Discharge June 15, 2024 Readmissions and Adverse Events After Discharge. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that t…

8637. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44047/psn-pdf
      September 09, 2015 - This study examined the use of a results manager tool by primary care physicians in Partners Healthcare … Although the vast majority of providers used the tool, many did not find that it was helpful for any … specific purpose and only 64% were satisfied with the tool.

8638. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42474/psn-pdf
      September 19, 2015 - Based on analysis of four studies using the Global Trigger Tool, the study concludes that between 210,000 … Although the accuracy of the Global Trigger Tool for assessing preventability of harm has been questioned … psnet.ahrq.gov/issue/err-human-building-safer-health-system https://psnet.ahrq.gov/issue/ihi-global-trigger-tool-measuring-adverse-events

8639. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39813/psn-pdf
      October 11, 2010 - This study describes a cardiopulmonary resuscitation (CPR) debriefing tool to guide postcode discussion … The authors share the practical development of the tool, its application, and lessons learned from implementation … They highlight how the tool and postcode discussions have guided identification and resolution of issues

8640. Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety. | PSNet
      psnet.ahrq.gov/issue/tapping-front-line-knowledge-identifying-problems-they-occur-helps-enhance-patient-safety
      July 21, 2009 - July 21, 2009 A trigger tool to identify adverse events in the intensive care unit.  … Development and evaluation of the Institute for Healthcare Improvement global trigger tool … April 4, 2011 'Global Trigger Tool' shows that adverse events in hospitals may be ten … April 1, 2010 Adverse drug event trigger tool: a practical methodology for measuring