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psnet.ahrq.gov/issue/what-context-features-might-be-important-determinants-effectiveness-patient-safety-practice
September 20, 2011 - Based on discussions from a 22-person expert panel, this study described four contextual domains judged
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psnet.ahrq.gov/issue/monitoring-patient-safety-primary-care-exploratory-study-using-depth-semistructured
December 14, 2016 - The participants described many barriers to patient safety in primary care and offered specific recommendations
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psnet.ahrq.gov/issue/implementing-electronic-health-record-default-settings-reduce-opioid-overprescribing-pilot
April 24, 2018 - An Annual Perspective described other initiatives to reduce opioid-related harm.
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psnet.ahrq.gov/node/33650/psn-pdf
May 01, 2007 - This, together with the other initiatives described, played a part in the development of patient safety … It described the NHS as having an old-
fashioned approach to learning lessons when things go wrong and … The "Safer Patients Initiative" has gone further than those described already in finding ways to directly
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psnet.ahrq.gov/node/49784/psn-pdf
February 01, 2017 - references
https://psnet.ahrq.gov//#references
point-of-care tests, such as the urine pregnancy test described … require manual result entry into
middleware or the patient record, as seen with the urine pregnancy test described … The type of pregnancy testing described in this case is CLIA waived.
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psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
May 01, 2012 - "( 4 ) First described and embraced in military history, situational awareness has more recently been … Three levels of situational awareness have been described: perception, understanding, and prediction. … Electronic health record–based solutions ( 15 ), such as safety-focused checklists, are well described
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psnet.ahrq.gov/node/33709/psn-pdf
July 01, 2011 - controlled studies of handover
training interventions were found.(9) Recently, Gakhar and colleagues described … and led to higher ratings
of handover quality and patient continuity.(10) More recently, others have described … Until then, the approaches described above provide a good starting point to guide
medical centers in
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psnet.ahrq.gov/node/33717/psn-pdf
September 01, 2011 - about 2000 studies on incident reporting but
found only 13 US reporting systems for which publications described … Some authors have described hospital incident
reporting systems with feedback loops that have been successful … 10,17,18) A panel of
incident reporting experts from several different industries and nations recently described
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psnet.ahrq.gov/web-mm/critical-opportunity-lost
February 17, 2017 - Sometimes going under the names of panic values or alert values, they were originally described as "values … Several such customized systems have been described in the literature.( 11,12 ) Broader implementation … Obviously, backup systems to those described above would need to be in place to trigger traditional phone
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psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - 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.
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psnet.ahrq.gov/node/33718/psn-pdf
October 01, 2011 - Yet mostly these kinds of implementation issues
aren't described in the patient safety literature, leaving … RW: And are they not described because we don't really know how to describe them? … For some people, context is a particular set of variables that
can be described and measured, and for … However, it has to be described fully and transparently and in the context of the theory or logic
model
-
psnet.ahrq.gov/node/49843/psn-pdf
October 01, 2018 - inflammatory diseases,
adrenal insufficiency, diabetic ketoacidosis, and acute pancreatitis.(13)
In the case described … However, nearly 40% of patients with sepsis
present with vague symptoms.(14) In addition, the patient described … For the patient described, the misdiagnosis delayed the correct diagnosis of cardiogenic
shock, leading … psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
patient described
-
psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd
February 26, 2025 - Yet mostly these kinds of implementation issues aren't described in the patient safety literature, leaving … RW : And are they not described because we don't really know how to describe them? … For some people, context is a particular set of variables that can be described and measured, and for … However, it has to be described fully and transparently and in the context of the theory or logic model
-
psnet.ahrq.gov/node/867022/psn-pdf
October 30, 2024 - subdural hematomas have been reported to
occur after initially negative head CTs, as in the patient described … Olivero and colleagues described 37 patients who underwent surgery for chronic
subdural hematomas, 7 … In a series described by Amrhein and
colleagues,25 the sensitivity and specificity of a non-enhanced … with concentration and memory were attributed
to the prior concussion (a cognitive bias sometimes described
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psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
January 01, 2024 - • While the patient described in this case does not appear to have met criteria for
septic shock … – Such imaging may have aided in the diagnosis of the child described above, as earlier
treatment … based on initial
information, to the exclusion of other more likely diagnoses, as occurred in the described … They often present like the
child described in this case, which may have led clinicians to anchor on … – With a fever and no crackles or wheezing on exam, the patient described above would
have had a PRS
-
psnet.ahrq.gov/node/865419/psn-pdf
March 27, 2024 - While the patient described in this case does not appear to have met criteria
for septic shock on her … Such imaging
may have aided in the diagnosis of the child described above, as earlier treatment of her … based on initial information, to the
exclusion of other more likely diagnoses, as occurred in the described … They often present like the child described in this case, which may
have led clinicians to anchor on … With a fever and no crackles or wheezing on exam, the patient
described above would have had a PRS of
-
psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
March 27, 2024 - While the patient described in this case does not appear to have met criteria for septic shock on her … Such imaging may have aided in the diagnosis of the child described above, as earlier treatment of her … , based on initial information, to the exclusion of other more likely diagnoses, as occurred in the described … They often present like the child described in this case, which may have led clinicians to anchor on … With a fever and no crackles or wheezing on exam, the patient described above would have had a PRS of
-
psnet.ahrq.gov/issue/after-mid-staffordshire-acknowledgement-through-learning-improvement
August 28, 2024 - English National Health Service
February 19, 2020
How well is quality improvement described
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psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
October 28, 2020 - diseases, adrenal insufficiency, diabetic ketoacidosis, and acute pancreatitis.( 13 )
In the case described … However, nearly 40% of patients with sepsis present with vague symptoms.( 14 ) In addition, the patient described … For the patient described, the misdiagnosis delayed the correct diagnosis of cardiogenic shock, leading … other potential life-threatening diagnoses that might present similarly, as in the case of the patient described
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psnet.ahrq.gov/web-mm/chest-tube-complications
September 27, 2023 - 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