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Showing results for "describes".

  1. Using Kotter's change model for implementing bedside handoff: a quality improvement project. | PSNet

    psnet.ahrq.gov/issue/using-kotters-change-model-implementing-bedside-handoff-quality-improvement-project
    September 23, 2020 - Commentary Using Kotter's change model for implementing bedside handoff: a quality improvement project. Citation Text: Small A, Gist D, Souza D, et al. Using Kotter's Change Model for Implementing Bedside Handoff: A Quality Improvement Project. J Nurs Care Qual. 2016;31(4):304-9. doi:10.…

  2. A Tale of Two Stories: Contrasting Views of Patient Safety. | PSNet

    psnet.ahrq.gov/issue/tale-two-stories-contrasting-views-patient-safety
    March 27, 2005 - Book/Report Classic A Tale of Two Stories: Contrasting Views of Patient Safety. Citation Text: A Tale of Two Stories: Contrasting Views of Patient Safety. Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1997. Copy Citation …

  3. Implementing a human factors approach to RCA(2) : tools, processes and strategies. | PSNet

    psnet.ahrq.gov/issue/implementing-human-factors-approach-rca2-tools-processes-and-strategies
    July 21, 2021 - Study Implementing a human factors approach to RCA(2) : tools, processes and strategies. Citation Text: Wiegmann DA, Wood LJ, Solomon DB, et al. Implementing a human factors approach to RCA(2) : tools, processes and strategies. J Healthc Risk Manag. 2021;41(1):31-46. doi:10.1002/jhrm.214…

  4. Framing family conversation after early diagnosis of iatrogenic injury and incidental findings. | PSNet

    psnet.ahrq.gov/issue/framing-family-conversation-after-early-diagnosis-iatrogenic-injury-and-incidental-findings
    November 14, 2011 - Study Framing family conversation after early diagnosis of iatrogenic injury and incidental findings. Citation Text: Barrios L, Tsuda S, Derevianko A, et al. Framing family conversation after early diagnosis of iatrogenic injury and incidental findings. Surg Endosc. 2009;23(11):2535-42…

  5. Making an infusion error: the second victims of infusion therapy-related medication errors. | PSNet

    psnet.ahrq.gov/issue/making-infusion-error-second-victims-infusion-therapy-related-medication-errors
    June 27, 2018 - Study Making an infusion error: the second victims of infusion therapy-related medication errors. Citation Text: Treiber LA, Jones JH. Making an Infusion Error: The Second Victims of Infusion Therapy-Related Medication Errors. J Infus Nurs. 2018;41(3):156-163. doi:10.1097/NAN.00000000000…

  6. Quality gaps identified through mortality review. | PSNet

    psnet.ahrq.gov/issue/quality-gaps-identified-through-mortality-review
    November 11, 2015 - Study Quality gaps identified through mortality review. Citation Text: Kobewka DM, van Walraven C, Turnbull J, et al. Quality gaps identified through mortality review. BMJ Qual Saf. 2017;26(2):141-149. doi:10.1136/bmjqs-2015-004735. Copy Citation Format: DOI Google Scholar …

  7. Adverse events detected by clinical surveillance on an obstetric service. | PSNet

    psnet.ahrq.gov/issue/adverse-events-detected-clinical-surveillance-obstetric-service
    September 11, 2009 - Study Adverse events detected by clinical surveillance on an obstetric service. Citation Text: Forster AJ, Fung I, Caughey S, et al. Adverse events detected by clinical surveillance on an obstetric service. Obstet Gynecol. 2006;108(5):1073-83. Copy Citation Format: Google…

  8. Errors, incidents and accidents in anaesthetic practice. | PSNet

    psnet.ahrq.gov/issue/errors-incidents-and-accidents-anaesthetic-practice
    April 06, 2011 - Commentary Classic Errors, incidents and accidents in anaesthetic practice. Citation Text: Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care. 1993;21(5…

  9. The association between night or weekend admission and hospitalization-relevant patient outcomes. | PSNet

    psnet.ahrq.gov/issue/association-between-night-or-weekend-admission-and-hospitalization-relevant-patient-outcomes
    November 26, 2014 - Study The association between night or weekend admission and hospitalization-relevant patient outcomes. Citation Text: Khanna R, Wachsberg K, Marouni A, et al. The association between night or weekend admission and hospitalization-relevant patient outcomes. J Hosp Med. 2011;6(1):10-4.…

  10. Exploring the role of salient distracting clinical features in the emergence of diagnostic errors and the mechanisms through which reflection counteracts mistakes. | PSNet

    psnet.ahrq.gov/issue/exploring-role-salient-distracting-clinical-features-emergence-diagnostic-errors-and
    July 03, 2014 - Study Exploring the role of salient distracting clinical features in the emergence of diagnostic errors and the mechanisms through which reflection counteracts mistakes. Citation Text: Mamede S, Splinter TAW, Van Gog T, et al. Exploring the role of salient distracting clinical features…

  11. Understanding whistleblowing: qualitative insights from nurse whistleblowers. | PSNet

    psnet.ahrq.gov/issue/understanding-whistleblowing-qualitative-insights-nurse-whistleblowers
    April 24, 2018 - Study Understanding whistleblowing: qualitative insights from nurse whistleblowers. Citation Text: Jackson D, Peters K, Andrew S, et al. Understanding whistleblowing: qualitative insights from nurse whistleblowers. J Adv Nurs. 2010;66(10):2194-201. doi:10.1111/j.1365-2648.2010.05365.x.…

  12. Teaching internal medicine residents quality improvement and patient safety: a lean thinking approach. | PSNet

    psnet.ahrq.gov/issue/teaching-internal-medicine-residents-quality-improvement-and-patient-safety-lean-thinking
    March 28, 2012 - Commentary Teaching internal medicine residents quality improvement and patient safety: a lean thinking approach. Citation Text: Kim CS, Lukela MP, Parekh V, et al. Teaching internal medicine residents quality improvement and patient safety: a lean thinking approach. Am J Med Qual. 201…

  13. Lessons learned from medical malpractice claims involving critical care nurses. | PSNet

    psnet.ahrq.gov/issue/lessons-learned-medical-malpractice-claims-involving-critical-care-nurses
    July 15, 2020 - Study Lessons learned from medical malpractice claims involving critical care nurses. Citation Text: Myers LC, Heard L, Mort E. Lessons learned from medical malpractice claims involving critical care nurses. Am J Crit Care. 2020;29(3):174-181. doi:10.4037/ajcc2020341. Copy Citation …

  14. Development of a medication safety and quality survey for small rural hospitals. | PSNet

    psnet.ahrq.gov/issue/development-medication-safety-and-quality-survey-small-rural-hospitals
    July 15, 2010 - Study Development of a medication safety and quality survey for small rural hospitals. Citation Text: Winterstein AG, Johns TE, Campbell KN, et al. Development of a Medication Safety and Quality Survey for Small Rural Hospitals. J Patient Saf. 2017;13(4):249-254. doi:10.1097/PTS.00000000…

  15. Use of specific indicators to detect warfarin-related adverse events.   | PSNet

    psnet.ahrq.gov/issue/use-specific-indicators-detect-warfarin-related-adverse-events
    October 19, 2022 - Study Use of specific indicators to detect warfarin-related adverse events.   Citation Text: Hartis CE, Gum MO, Lederer JW. Use of specific indicators to detect warfarin-related adverse events. American Journal of Health-System Pharmacy. 2005;62(16). doi:10.2146/ajhp040404. Copy Cita…

  16. Follow-up of outpatient test results: a survey of house-staff practices and perceptions. | PSNet

    psnet.ahrq.gov/issue/follow-outpatient-test-results-survey-house-staff-practices-and-perceptions
    July 14, 2010 - Study Follow-up of outpatient test results: a survey of house-staff practices and perceptions. Citation Text: Lin JJ, Dunn A, Moore C. Follow-up of outpatient test results: a survey of house-staff practices and perceptions. Am J Med Qual. 2006;21(3):178-84. Copy Citation Format: …

  17. Rating recommendations for consumers about patient safety: sense, common sense, or nonsense? | PSNet

    psnet.ahrq.gov/issue/rating-recommendations-consumers-about-patient-safety-sense-common-sense-or-nonsense
    January 06, 2017 - Study Rating recommendations for consumers about patient safety: sense, common sense, or nonsense? Citation Text: Weingart SN, Morway L, Brouillard D, et al. Rating recommendations for consumers about patient safety: sense, common sense, or nonsense? Jt Comm J Qual Patient Saf. 2009;35(4…

  18. "Health courts" and accountability for patient safety. | PSNet

    psnet.ahrq.gov/issue/health-courts-and-accountability-patient-safety
    February 17, 2011 - Commentary "Health courts" and accountability for patient safety. Citation Text: Mello MM, Studdert DM, Kachalia A, et al. "Health courts" and accountability for patient safety. Milbank Q. 2006;84(3):459-92. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML …

  19. Implementation of a "second victim" program in a pediatric hospital. | PSNet

    psnet.ahrq.gov/issue/implementation-second-victim-program-pediatric-hospital
    December 18, 2013 - Study Implementation of a "second victim" program in a pediatric hospital. Citation Text: Krzan KD, Merandi J, Morvay S, et al. Implementation of a "second victim" program in a pediatric hospital. Am J Health Syst Pharm. 2015;72(7):563-7. doi:10.2146/ajhp140650. Copy Citation Forma…

  20. Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios. | PSNet

    psnet.ahrq.gov/issue/inattentional-blindness-and-failures-rescue-deteriorating-patient-critical-care-emergency-and
    October 12, 2016 - Study Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios. Citation Text: Jones A, Johnstone M-J. Inattentional blindness and failures to rescue the deteriorating patient in critical care, em…
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