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psnet.ahrq.gov/node/49654/psn-pdf
June 01, 2012 - Understand the frequency of errors and adverse events in the transfer of patients between hospitals.
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psnet.ahrq.gov/node/33841/psn-pdf
September 01, 2017 - You actually have to configure it to make it efficient, make it save time, understand how it works.
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - ten different alarms going off at the same time without it being integrated in a
way that they can understand
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psnet.ahrq.gov/periodic-issue/periodic-issue-378
February 01, 2023 - Affairs (VA) nursing homes with diverse safety climate ratings (high, medium, low) were interviewed to understand
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psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - used in units with different patient populations, so it is essential that health care organizations understand
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - Understand the importance of early management of obstetric hemorrhage.
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psnet.ahrq.gov/node/73103/psn-pdf
March 31, 2021 - helpful.10
Conclusion
Engaging patients after discharge from the hospital offers opportunities to understand
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - Conduciveness to change The detection method should capture sufficient detail to understand the
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - Learning Objectives Understand the biases that may contribute to overcalling medical errors Describe
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - Clinicians who order radiology studies need to understand the importance of providing enough medical
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psnet.ahrq.gov/web-mm/volume-too-low-and-out
July 01, 2017 - Take-Home Points
Many aspects of the care of children require age and/or weight-based considerations to understand
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psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
May 01, 2008 - Understand that substance use impacts the presentation of pain and pain management.
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psnet.ahrq.gov/node/866992/psn-pdf
May 29, 2024 - How do we understand the value of drug checking as a
component of harm reduction services?
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - To understand the causes of errors, we must examine what happened, what was the root cause, and what
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - Understand the risk factors for and frequency of perforation during colonoscopy.
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - The nurse’s concern was not resolved, but the resident did not understand the requirements of the time-out
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psnet.ahrq.gov/node/49870/psn-pdf
August 10, 2019 - Understand that both upper endoscopy and colonoscopy are usually indicated in iron deficiency
anemia
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psnet.ahrq.gov/node/42797/psn-pdf
June 10, 2018 - Understanding and managing IV container overfill.
June 10, 2018
ISMP Medication Safety Alert! Acute care edition. November 14, 2013;18:1-4.
https://psnet.ahrq.gov/issue/understanding-and-managing-iv-container-overfill
This newsletter article reports on concerns associated with chemotherapy preparations due to varia…
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psnet.ahrq.gov/node/40572/psn-pdf
June 27, 2018 - Understanding care transitions as a patient safety issue.
June 27, 2018
Butterfield S; Stegel C; Glock S; Tartaglia D.
https://psnet.ahrq.gov/issue/understanding-care-transitions-patient-safety-issue
This article describes a regional collaborative to enhance care transitions of Medicare beneficiaries by
improving …
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psnet.ahrq.gov/node/45338/psn-pdf
July 20, 2016 - Understanding models of error and how they apply in
clinical practice.
July 20, 2016
Garfield S, Franklin BD. Pharm J. June 14, 2016.
https://psnet.ahrq.gov/issue/understanding-models-error-and-how-they-apply-clinical-practice
Human error and fallibility are a part of health care delivery that can be exacerbated b…