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Showing results for "addresses".

161. Transition to Nowhere | PSNet
     psnet.ahrq.gov/web-mm/transition-nowhere
     March 21, 2009 - Busy inpatient teams are unlikely to have time to assess and address all of these areas at the time of … One solution to this "transition to nowhere" could involve a systems approach that addresses gaps in

162. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49391/psn-pdf
     February 01, 2003 - The Commentary This case addresses the medical error of neglecting to assess possible underlying medical

163. Miscommunication in the OR Leads to Anticoagulation Mishap | PSNet
     psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
     May 08, 2019 - hierarchy, conflicting roles and role ambiguity, and interpersonal power and conflict.( 4 ) To try to address … communication errors, health care organizations must dedicate themselves to building a safety culture that addresses … rates.( 14 ) However, building an optimal safety culture is challenging: no single intervention can address

164. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73229/psn-pdf
     May 26, 2021 - Closed-loop communication, in which the person speaking addresses a person by name and the receiving

165. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49688/psn-pdf
     August 21, 2013 - Rather than ACL repair, the surgeon performed microfracture to address damage to the intraarticular … https://psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers The Commentary This case addresses … instructions and follow-up verbal interactions were inadequate and, therefore, failed to uncover or address

166. In Conversation with…Pat Croskerry, MD, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
     June 01, 2010 - memory, and decision making. 8  Lack of sleep is associated with increased medical error. 9 ,10   To address … There are several potential solutions to address environmental system issues. … Conclusions ED safety requires a multi-faceted approach that addresses provider knowledge, experience … poorly designed measures, as described by Wachter and colleagues. 20  Only an integrated approach that addresses

167. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33629/psn-pdf
     March 01, 2006 - teamwork, develop skills of teamwork, and enhance attitudes concerning teamwork.(2) Didactic training may address … skills and attitudes The readings, lectures, and group exercises preceding simulations purposefully addresses

168. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33772/psn-pdf
     September 01, 2014 - RG: Different solutions are needed to address the varied causes of overuse and its harm. … It addresses the so-called moral hazard that occurs when people use more health care services because

169. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50859/psn-pdf
     January 31, 2020 - with untapped potential, and the field is reaching the point where it could use that technology to address … What we have talked about so far addresses potentially missed diagnoses, but what you have described … These are the philosophical questions that we have to address in parallel with the technology being

170. In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
     November 16, 2022 - To address some of those gaps, we created a trigger in the electronic health record. … elements (including people) can go right or wrong, HFE uses human-centered design processes and methods to address … This type of solution inherently addresses core design problems rather than relying on humans to adapt … the constant elements of the patient journey, SEIPS 2.0 emphasizes patient engagement and SEPIS 3.0 addresses … Systems engineering focuses on the development and oversight of a system to address a need.

171. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72618/psn-pdf
     December 23, 2020 - systematic approach to understanding the problem and identifying solutions.3  Identify ideas that address … Broad and targeted approaches may both be needed to address the scope of the challenge. … with the existing workflow and that the clinical team agrees with the root cause the intervention addresses

172. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49494/psn-pdf
     January 01, 2006 - culture where everyone looks critically at clinical outcomes, focuses on best patient care, and actively addresses

173. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60543/psn-pdf
     May 27, 2020 - evidence, and may not be relevant to current practice.1-3 The literature regarding VOs that does exist addresses … prevent wrong site, wrong procedure, and wrong person surgery was created by the Joint Commission to address … of the operative site, and conducting a “time-out.”9 The preoperative verification process seeks to address

174. When "Psychiatric" Symptoms Are Not | PSNet
     psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
     September 20, 2011 - The Commentary This case addresses the medical error of neglecting to assess possible underlying medical

175. Check the Anesthesia Machine | PSNet
     psnet.ahrq.gov/web-mm/check-anesthesia-machine
     August 01, 2006 - However, this type of forcing function only addresses one specific error, while overdoses of inhalational

176. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49458/psn-pdf
     September 01, 2004 - Results of a survey of a random sample of 1,311 US internists suggest that the average internist addresses

177. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49653/psn-pdf
     May 01, 2012 - day), (iii) the attending with the team pulls the information shared into a plan that systematically addresses

178. One Dose, Fifty Pills | PSNet
     psnet.ahrq.gov/web-mm/one-dose-fifty-pills
     January 13, 2021 - culture where everyone looks critically at clinical outcomes, focuses on best patient care, and actively addresses

179. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities | PSNet
     psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
     November 27, 2019 - Closed-loop communication , in which the person speaking addresses a person by name and the receiving

180. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet
     psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
     February 26, 2025 - Although they appeared very thorough, sometimes the questions did not address the complexities of the … This redesigned RCA methodology aimed to address the most persistent ineffectual issues with traditional … This flexibility also allows for innovation from organizations that want to expand their scope to address … Another health system addresses emotional harms alongside physical ones, 6 and another integrates an … The introduction of RCA 2 addresses many challenges associated with traditional RCA processes, emphasizing