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psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
February 24, 2021 - The surgeon utilized a supraclavicular approach for the guidewire placement and was having significant
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - Many providers and health care organizations lack any organized approach to preventing transitional
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psnet.ahrq.gov/node/50930/psn-pdf
February 21, 2020 - Increasingly, patient safety initiatives emphasize the benefit of a multidisciplinary, team-based approach
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psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
June 28, 2023 - Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling
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January 31, 2024
Innovation
Contact
…
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psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
December 18, 2019 - The U-ARE Protocol: A Pragmatic Approach to Decisional Capacity Assessment for Clinical Research.
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psnet.ahrq.gov/node/49863/psn-pdf
May 01, 2019 - Finally, a systems-based approach to prevent the adverse event in this case would focus on the technology
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psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
December 22, 2018 - Interprofessional collaboration should be viewed as a key organizational and professional approach to
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psnet.ahrq.gov/node/49668/psn-pdf
October 01, 2012 - Buprenorphine and the Medically Ill Patient
October 1, 2012
McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
The Case
A 60-year-old man with a 15-year history of oxycodone dependence presented to a substance …
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psnet.ahrq.gov/node/33709/psn-pdf
July 01, 2011 - In Post-Anesthesia Care Units (PACU), this approach proved highly effective in improving
handover quality
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psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - An alternate approach would be to
pursue throughout health system staggered schedule starts for trainees
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psnet.ahrq.gov/node/836939/psn-pdf
April 27, 2022 - To meet the need, the team decided to try a new
approach to staffing.
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psnet.ahrq.gov/web-mm/one-dose-fifty-pills
January 13, 2021 - Differences in approach should be discussed with trainees as colleagues, not mandated from the “top.”
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psnet.ahrq.gov/perspective/telemedicine-and-patient-safety
September 01, 2016 - The traditional model of episodic and hospital-based care is being replaced by a patient-centric approach … How do you approach both of those as you try to move this field forward? … It's one that we should approach very carefully as a society.
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psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md
September 01, 2016 - How do you approach both of those as you try to move this field forward? … It's one that we should approach very carefully as a society. … The traditional model of episodic and hospital-based care is being replaced by a patient-centric approach
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psnet.ahrq.gov/node/44689/psn-pdf
February 24, 2018 - concept of a just culture has become popular for balancing individual accountability with a systems
approach … https://psnet.ahrq.gov/perspective/accountability-patient-safety
https://psnet.ahrq.gov/primer/systems-approach … https://psnet.ahrq.gov/primer/systems-approach
https://psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
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psnet.ahrq.gov/node/44812/psn-pdf
February 15, 2017 - Investigators also tested a combined approach. … Although both team training and system redesign
individually demonstrated improvement, the combined approach … was more successful than either individual
approach.
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psnet.ahrq.gov/perspective/accountability-patient-safety
January 01, 2018 - New articles exploring the role of individual skill in safety have heightened the need for an approach … This approach to mistakes was an ineffective strategy for preventing further patient safety mishaps, … This approach was codified as the cornerstone for the field of patient safety by its central role in … The systems-based approach was not only more likely to fix underlying patient safety problems, but … A prior PSNet perspective summarizes a stepwise approach for managing problem behaviors.
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psnet.ahrq.gov/node/46781/psn-pdf
August 20, 2018 - risk industries may not be
straightforward: a qualitative study of the hierarchy of
risk controls approach … risk industries may not be straightforward: a
qualitative study of the hierarchy of risk controls approach … /errors-and-near-misses-what-health-care-could-learn-aviation
https://psnet.ahrq.gov/primer/systems-approach
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psnet.ahrq.gov/node/41858/psn-pdf
November 21, 2012 - This study
applied the systems approach to analyze cases presented at surgical M&M conferences over … disorganized-care-findings-iterative-depth-analysis-surgical-morbidity-and-mortality
https://psnet.ahrq.gov/primer/systems-approach … /discussion-medical-errors-morbidity-and-mortality-conferences
https://psnet.ahrq.gov/issue/systems-approach-morbidity-and-mortality-conference
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psnet.ahrq.gov/issue/when-should-students-learn-about-ethics-professionalism-and-patient-safety63
August 14, 2013 - Topics
Approach to Improving Safety
Students
Resource Type
Commentary … Journal Article
Commentary
A multi-tiered approach … Journal Article
Commentary
Medical improv: a novel approach