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3521. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33825/psn-pdf
      January 01, 2017 - Tools also tend to focus on a linear or temporal view of an event, rather than a systems view of events … Focusing more specifically on problems with RCA tools and techniques, Card described "the problem with … Use appropriate tools and identify viable corrective actions RCA2 tools (e.g., interviewing techniques … Several studies have suggested opportunities for improvement, including redesigning the process and tools

3522. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33786/psn-pdf
      May 01, 2015 - cases in the operating room to study surgical motions.(2) Recent advances in video-based assessment tools … Video captures the rich context surrounding care activities, such as tools, equipment, and team interactions … As more validated assessment tools (3,4), clinical protocols, and benchmark performance data https:/ … We have seen increased interest in developing validated assessment tools, which should lay a foundation … Assessing team performance in the operating room: development and use of a "black-box" recorder and other tools

3523. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33811/psn-pdf
      June 01, 2016 - familiar with root cause analysis, failure mode and effect analysis, and the benefits of using these tools … participants can read about how other hospitals have tackled problems, and they will receive copies of the tools … limited resources and personnel in most hospitals, the poster session equips attendees with essential tools

3524. Operating at night does not increase the risk of intraoperative adverse events. | PSNet
      psnet.ahrq.gov/issue/operating-night-does-not-increase-risk-intraoperative-adverse-events
      July 01, 2017 - January 23, 2017 Development of trigger tools for surveillance of adverse events in ambulatory … 13, 2018 Intraoperative surgical performance measurement and outcomes: choose your tools

3525. Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency. | PSNet
      psnet.ahrq.gov/issue/liquid-medication-dosing-errors-hispanic-parents-role-health-literacy-and-english-proficiency
      December 14, 2016 - Related Resources From the Same Author(s) Liquid medication errors and dosing tools … December 14, 2016 Pictograms, units and dosing tools, and parent medication errors: a

3526. A simulation-based evaluation of methods to estimate the impact of an adverse event on hospital length of stay. | PSNet
      psnet.ahrq.gov/issue/simulation-based-evaluation-methods-estimate-impact-adverse-event-hospital-length-stay
      December 23, 2011 - November 10, 2015 Applying trigger tools to detect adverse events associated with outpatient … Resources Measuring the overall development of patient safety in a new hospital using trigger tools

3527. Medicines management, medication errors and adverse medication events in older people referred to a community nursing service: a retrospective observational study. | PSNet
      psnet.ahrq.gov/issue/medicines-management-medication-errors-and-adverse-medication-events-older-people-referred
      January 06, 2016 - April 24, 2018 Liquid medication errors and dosing tools: a randomized controlled experiment … May 31, 2017 Pictograms, units and dosing tools, and parent medication errors: a randomized

3528. Infection control assessment of ambulatory surgical centers. | PSNet
      psnet.ahrq.gov/issue/infection-control-assessment-ambulatory-surgical-centers
      October 19, 2012 - December 21, 2014 Applying trigger tools to detect adverse events associated with outpatient … October 1, 2014 Development of trigger tools for surveillance of adverse events in ambulatory

3529. Advancing a More Health-Literate Approach to Patient Safety | PSNet
      psnet.ahrq.gov/issue/advancing-more-health-literate-approach-patient-safety
      May 31, 2017 - April 24, 2018 Liquid medication errors and dosing tools: a randomized controlled experiment … December 14, 2016 Pictograms, units and dosing tools, and parent medication errors: a

3530. Unit of measurement used and parent medication dosing errors. | PSNet
      psnet.ahrq.gov/issue/unit-measurement-used-and-parent-medication-dosing-errors
      June 04, 2014 - May 31, 2017 Liquid medication errors and dosing tools: a randomized controlled experiment … December 14, 2016 Pictograms, units and dosing tools, and parent medication errors: a

3531. Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. | PSNet
      psnet.ahrq.gov/issue/developing-indicators-inpatient-adverse-drug-events-through-nonlinear-analysis-using
      December 23, 2011 - February 3, 2011 Applying trigger tools to detect adverse events associated with outpatient … August 4, 2021 Development of trigger tools for surveillance of adverse events in ambulatory

3532. Lost in translation: medication labeling for immigrant families. | PSNet
      psnet.ahrq.gov/issue/lost-translation-medication-labeling-immigrant-families
      May 31, 2017 - May 31, 2017 Liquid medication errors and dosing tools: a randomized controlled experiment … December 14, 2016 Pictograms, units and dosing tools, and parent medication errors: a

3533. Predictors of misunderstanding pediatric liquid medication instructions. | PSNet
      psnet.ahrq.gov/issue/predictors-misunderstanding-pediatric-liquid-medication-instructions
      December 21, 2017 - Related Resources From the Same Author(s) Pictograms, units and dosing tools … May 31, 2017 Liquid medication errors and dosing tools: a randomized controlled experiment

3534. Hospitalist handoffs: a systematic review and task force recommendations. | PSNet
      psnet.ahrq.gov/issue/hospitalist-handoffs-systematic-review-and-task-force-recommendations
      September 09, 2013 - December 6, 2023 A systematic review of the literature on the evaluation of handoff tools … July 2, 2014 Review of computerized physician handoff tools for improving the quality

3535. Liquid medication dosing errors in children: role of provider counseling strategies. | PSNet
      psnet.ahrq.gov/issue/liquid-medication-dosing-errors-children-role-provider-counseling-strategies
      August 14, 2014 - December 21, 2014 Liquid medication errors and dosing tools: a randomized controlled … May 31, 2017 Pictograms, units and dosing tools, and parent medication errors: a randomized

3536. Partial do-not-resuscitate orders: a hazard to patient safety and clinical outcomes? | PSNet
      psnet.ahrq.gov/issue/partial-do-not-resuscitate-orders-hazard-patient-safety-and-clinical-outcomes
      April 24, 2018 - April 24, 2018 Liquid medication errors and dosing tools: a randomized controlled experiment … May 31, 2017 Pictograms, units and dosing tools, and parent medication errors: a randomized

3537. Ethical considerations on disclosure when medical error is discovered during medicolegal death investigation. | PSNet
      psnet.ahrq.gov/issue/ethical-considerations-disclosure-when-medical-error-discovered-during-medicolegal-death
      December 14, 2016 - Related Resources From the Same Author(s) Liquid medication errors and dosing tools … May 31, 2017 Pictograms, units and dosing tools, and parent medication errors: a randomized

3538. Patterns of medical and nursing staff communication in nursing homes: implications and insights from complexity science. | PSNet
      psnet.ahrq.gov/issue/patterns-medical-and-nursing-staff-communication-nursing-homes-implications-and-insights
      December 22, 2018 - July 2, 2009 Liquid medication errors and dosing tools: a randomized controlled experiment … May 31, 2017 Pictograms, units and dosing tools, and parent medication errors: a randomized

3539. 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 - 22, 2017 Understanding liability risk from using health care artificial intelligence tools … April 28, 2021 View More Related Resources Decision support tools

3540. The incidence and cost of adverse events in Victorian hospitals 2003-04. | PSNet
      psnet.ahrq.gov/issue/incidence-and-cost-adverse-events-victorian-hospitals-2003-04
      July 13, 2010 - June 26, 2019 Liquid medication errors and dosing tools: a randomized controlled experiment … December 14, 2016 Pictograms, units and dosing tools, and parent medication errors: a