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psnet.ahrq.gov/issue/root-cause-analysis-core-problem-solving-and-corrective-action-second-edition
June 09, 2011 - Book/Report
Classic
Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition.
Citation Text:
Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition. Oakes D. Milwaukee, WI: ASQ Quality Press; 2019. IS…
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psnet.ahrq.gov/node/45953/psn-pdf
July 22, 2020 - Root Cause Analysis in Health Care: A Joint Commission
Guide to Analysis and Corrective Action of Sentinel and
Adverse Events.
July 22, 2020
Oakbrook Terrace, IL: Joint Commission Resources; 2020. ISBN: 9781635851618.
https://psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and-…
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - Not only must care be performed correctly and safely, but for a subset of patients experiencing time-sensitive … It is critical that clinical assessments and procedures be performed correctly and safely to reduce the … adds on top of that is the assessment of when medical interventions are needed, are they done and done correctly … So, within that entire span of care for that individual, did we do our part in getting it set up correctly
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psnet.ahrq.gov/node/42515/psn-pdf
October 24, 2013 - Using four-phased unit-based patient safety walkrounds
to uncover correctable system flaws.
October 24, 2013
Taylor AM, Chuo J, Figueroa-Altmann A, et al. Using four-phased unit-based patient safety walkrounds to
uncover correctable system flaws. Jt Comm J Qual Patient Saf. 2013;39(9):396-403.
https://psnet.ahrq.g…
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psnet.ahrq.gov/issue/prevalence-and-factors-associated-patient-requested-corrections-medical-record-through-use
October 02, 2024 - Study
Prevalence and factors associated with patient-requested corrections to the medical record through use of a patient portal: findings from a national survey.
Citation Text:
Nguyen OT, Hong Y-R, Alishahi Tabriz A, et al. Prevalence and factors associated with patient-requested correc…
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psnet.ahrq.gov/node/43393/psn-pdf
July 30, 2014 - Effectiveness of the surgical safety checklist in correcting
errors: a literature review applying Reason's Swiss
cheese model.
July 30, 2014
Collins SJ, Newhouse R, Porter J, et al. Effectiveness of the surgical safety checklist in correcting errors: a
literature review applying Reason's Swiss cheese model. AORN J…
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psnet.ahrq.gov/node/37688/psn-pdf
April 16, 2008 - Role of registered nurses in error prevention, discovery
and correction.
April 16, 2008
Rogers AE, Dean GE, Hwang W-T, et al. Role of registered nurses in error prevention, discovery and
correction. Qual Saf Health Care. 2008;17(2):117-21. doi:10.1136/qshc.2007.022699.
https://psnet.ahrq.gov/issue/role-registered-…
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psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
September 01, 2017 - functionality unexpectedly after a routine system upgrade; and inadvertent interactions between otherwise correctly … otherwise not working as designed.( 15 )
Network problem prevented remote allergy checking from working correctly … enter order for 38-fold overdose of medication.( 28 )
Health IT is well-designed and working correctly … room following patient scan.( 29 )
Health IT is working as designed and was configured and used correctly
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psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
September 01, 2017 - functionality unexpectedly after a routine system upgrade; and inadvertent interactions between otherwise correctly … otherwise not working as designed.( 15 )
Network problem prevented remote allergy checking from working correctly … enter order for 38-fold overdose of medication.( 28 )
Health IT is well-designed and working correctly … room following patient scan.( 29 )
Health IT is working as designed and was configured and used correctly
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psnet.ahrq.gov/node/49572/psn-pdf
October 01, 2008 - The Commentary
Correctly identifying a patient seems like a straightforward task.
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psnet.ahrq.gov/node/49540/psn-pdf
August 21, 2007 - that ensures that
there is no damage to the device, that all components match the device and attach correctly … proven tool in such industries as aviation, where a highly complex set of
equipment must function correctly
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psnet.ahrq.gov/node/49516/psn-pdf
August 01, 2006 - model these skills and be vigilant to ensure that what they are
passing on is accurate and performed correctly … .(6) The reassurance offered to those in training by watching
their faculty member correctly make diagnoses
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psnet.ahrq.gov/node/33656/psn-pdf
September 01, 2007 - a
resident correctly perceives that something is amiss in a patient whose objective signs were fine. … Yes, some people will not use that information correctly or not use it at all, but
the dominant effect
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psnet.ahrq.gov/node/33672/psn-pdf
September 01, 2008 - are definitely lots of opportunities to use barcode technology to make sure that lab
specimens are correctly … patient safety impact but
definitely could increase the efficiency of the hospital if it's implemented correctly
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psnet.ahrq.gov/web-mm/watch-warfarin
December 01, 2013 - anticoagulant, with 30 million prescriptions written per year in the United States alone.( 1 ) When taken correctly … The medical team correctly continued the patient's warfarin on admission; patients in whom warfarin is
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psnet.ahrq.gov/web-mm/worst-headache
July 01, 2016 - diagnosis, (ii) not understanding the limitations of computed tomography (CT), and (iii) not performing or correctly … Even when these tests are performed, however, clinicians sometimes fail to interpret the results correctly
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psnet.ahrq.gov/node/45949/psn-pdf
July 11, 2017 - Beyond medication reconciliation: the correct medication
list.
July 11, 2017
Rose AJ, Fischer SH, Paasche-Orlow MK. Beyond Medication Reconciliation: The Correct Medication List.
JAMA. 2017;317(20):2057-2058. doi:10.1001/jama.2017.4628.
https://psnet.ahrq.gov/issue/beyond-medication-reconciliation-correct-medicati…
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psnet.ahrq.gov/node/860734/psn-pdf
January 17, 2024 - These patients had to lobby for correct diabetes
diagnoses. Was their race a reason?
January 17, 2024
Sable-Smith B. KFF Health News. January 9, 2024.
https://psnet.ahrq.gov/issue/these-patients-had-lobby-correct-diabetes-diagnoses-was-their-race-reason
Implicit biases can contribute to extended misdiagnoses.…
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Emergency Department and with more left to give as part of the massive transfusion protocol that had been correctly
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psnet.ahrq.gov/node/50843/psn-pdf
January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat
Hyponatremia
January 29, 2020
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet].
2020.
https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
The Case
A 54-year-old man was brought t…