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Total Results: 6,755 records

Showing results for "described".

441. Trade-offs between voice and silence: a qualitative exploration of oncology staff's decisions to speak up about safety concerns. | PSNet
     psnet.ahrq.gov/issue/trade-offs-between-voice-and-silence-qualitative-exploration-oncology-staffs-decisions-speak
     November 05, 2014 - nurses in an oncology unit all agreed on the importance of speaking up in unsafe situations, they described

442. Workplace violence against anesthesiologists: we are not immune to this patient safety threat. | PSNet
     psnet.ahrq.gov/issue/workplace-violence-against-anesthesiologists-we-are-not-immune-patient-safety-threat
     March 06, 2005 - About 20% of respondents described experiencing physical violence at work at least once; very few were

443. Clinical faculty: taking the lead in teaching quality improvement and patient safety. | PSNet
     psnet.ahrq.gov/issue/clinical-faculty-taking-lead-teaching-quality-improvement-and-patient-safety
     July 01, 2017 - Patient safety has been described as an unmet need in physician training.

444. How do we learn about error? A cross-sectional study of urology trainees. | PSNet
     psnet.ahrq.gov/issue/how-do-we-learn-about-error-cross-sectional-study-urology-trainees
     October 21, 2010 - In this study, surgical trainees described factors influencing their decisions not to disclose errors

445. Improving diagnosis in health care—the next imperative for patient safety. | PSNet
     psnet.ahrq.gov/issue/improving-diagnosis-health-care-next-imperative-patient-safety
     July 15, 2015 - The authors also acknowledge potential challenges to implementing the systems and process changes described

446. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients | PSNet
     psnet.ahrq.gov/web-mm/nonsustained-ventricular-tachycardia-after-acute-coronary-syndromes-recognizing-high-risk
     September 20, 2011 - In the case described above, a patient who underwent percutaneous coronary intervention developed a brief … Most episodes of NSVT, like the one described above, are just a few beats in duration. … overemphasized.( 7 ) Nursing units and health care teams that care for high-risk patients (such as the one described

447. Falling Between the Cracks in the Software | PSNet
     psnet.ahrq.gov/web-mm/falling-between-cracks-software
     March 09, 2011 - work with other systems or products without special effort on the part of the user.( 1 ) In the case described … What's notable about the case described is that it takes place within one health care delivery system … Why might the health system described still lack interoperability between its inpatient and outpatient

448. Getting the (Right) Doctor, Right Away | PSNet
     psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
     July 01, 2011 - The radiologist in the case described above did not know how to access the call schedule to find out … Furthermore, those who might need to page a provider—for example, the radiologist described in the case—might … If the case of the patient described above were to take place at our hospital today, the radiologist

449. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49796/psn-pdf
     June 01, 2017 - Chest tube complications have been described most often in the trauma literature, with incidences varying … to help guide nurses in when to remove chest tubes.(13,14) Unfortunately, clamping trials are not described … Funk and colleagues (15) have described a chest tube care path that outlines an algorithm for safe removal

450. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49850/psn-pdf
     January 01, 2019 - costs, for example by reducing the use of unnecessary red blood cell transfusions.(6) In the case described … users who could potentially use the order set and be affected by the change, such as the resident (described … In the case described, one such metric might have been time from initiation of heparin to the first

451. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45222/psn-pdf
     June 08, 2016 - An earlier article described the implementation of the program, which involved collaboration between

452. A Room Without Orders | PSNet
     psnet.ahrq.gov/web-mm/room-without-orders
     September 01, 2011 - Therefore, it is possible that the staff nurse assigned to perform admission activities in the case described … material resources (56%), and communication issues (38%).( 5 ) Although the root cause of the errors described … Although the details around the communication in the case described are unknown, below is a suggested … Improving Processes to Reduce Risk of Error A previous AHRQ WebM&M commentary described best practices … a bed on the receiving unit based on information provided by the electronic bed board application (described

453. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49654/psn-pdf
     June 01, 2012 - The orthopedic surgeon briefly described a 92-year-old woman with a history of dementia who had a left … They were handwritten and difficult to read but described "profound hypotension" at the start of the … In the described case, it is clear that communication errors throughout the process were a primary contributor … If best practices described had been employed, the outcome may have been different.

454. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49852/psn-pdf
     February 01, 2019 - reasons, such as patient/family preference or expediting diagnostic evaluation (5), the most commonly described … systems, which may help mitigate discontinuity of care, remains inadequate.(15) As we see in the case described … experience worse outcomes, which cannot be attributed to their illness severity alone.(13,14,17) The described … transfers (by obviating unnecessary transfers) without impacting patient outcomes.(25) In the case described

455. Infusional chemotherapy and medication errors in a tertiary care pediatric cancer unit in a resource-limited setting. | PSNet
     psnet.ahrq.gov/issue/infusional-chemotherapy-and-medication-errors-tertiary-care-pediatric-cancer-unit-resource
     October 29, 2012 - A past AHRQ WebM&M perspective described a widely known incident of chemotherapy medication overdose

456. Electronic health record reviews to measure diagnostic uncertainty in primary care. | PSNet
     psnet.ahrq.gov/issue/electronic-health-record-reviews-measure-diagnostic-uncertainty-primary-care
     August 20, 2018 - Researchers conducted a retrospective chart review of primary care visits to assess how clinicians described

457. The expanding role of antimicrobial stewardship programs in hospitals in the United States: lessons learned from a multisite qualitative study. | PSNet
     psnet.ahrq.gov/issue/expanding-role-antimicrobial-stewardship-programs-hospitals-united-states-lessons-learned
     March 04, 2015 - A past WebM&M commentary described the harms associated with inappropriate antibiotic use.

458. Differences of reasons for alert overrides on contraindicated co-prescriptions by admitting department. | PSNet
     psnet.ahrq.gov/issue/differences-reasons-alert-overrides-contraindicated-co-prescriptions-admitting-department
     January 23, 2017 - Alert fatigue is a well-described limitation of clinical decision support systems.

459. The effects of electronic prescribing by community-based providers on ambulatory medication safety. | PSNet
     psnet.ahrq.gov/issue/effects-electronic-prescribing-community-based-providers-ambulatory-medication-safety
     March 04, 2015 - A previous AHRQ WebM&M perspective described the importance of thoughtful application of CDSS for medication

460. What are the safety risks for patients undergoing treatment by multiple specialties: a retrospective patient record review study. | PSNet
     psnet.ahrq.gov/issue/what-are-safety-risks-patients-undergoing-treatment-multiple-specialties-retrospective
     March 18, 2013 - A previous AHRQ WebM&M commentary described benefits and drawbacks associated with comanagement.