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Total Results: 1,773 records

Showing results for "details".

441. Root cause analysis of cases involving diagnosis. | PSNet
     psnet.ahrq.gov/issue/root-cause-analysis-cases-involving-diagnosis
     August 28, 2019 - Commentary Root cause analysis of cases involving diagnosis. Citation Text: Graber ML, Castro GM, Danforth M, et al. Root cause analysis of cases involving diagnosis. Diagnosis (Berl). 2024;11(4):353-368. doi:10.1515/dx-2024-0102. Copy Citation Format: DOI Google Scholar Bi…

442. Medication Safety and Hospital Referrals: A Report by the Health and Disability Commissioner. | PSNet
     psnet.ahrq.gov/issue/medication-safety-and-hospital-referrals-report-health-and-disability-commissioner
     March 30, 2022 - Book/Report Medication Safety and Hospital Referrals: A Report by the Health and Disability Commissioner. Citation Text: Medication Safety and Hospital Referrals: A Report by the Health and Disability Commissioner. Paterson R. Auckland, NZ; Office of the Health and Disability Commiss…

443. Teamwork Training | PSNet
     psnet.ahrq.gov/primer/teamwork-training
     September 15, 2024 - preoperative "time out," based on teamwork training principles, in which all team members review the details

444. In Conversation With… Richard Platt, MD, MSc | PSNet
     psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
     October 01, 2016 - trail of data showing every step in which multiple health care professionals took care of countless details … medications, but I soon realized that I only initiated a Rube Goldberg–like machine that handled all the details … work productively with biostatisticians, clinician data scientists should know enough of the technical details

445. When Things Go Wrong: Responding to Adverse Events. | PSNet
     psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events
     November 19, 2014 - Book/Report Classic When Things Go Wrong: Responding to Adverse Events. Citation Text: When Things Go Wrong: Responding to Adverse Events. Boston, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2006. Copy Citation Save …

446. Submit Case | PSNet
     psnet.ahrq.gov/submit-case-landing
     March 25, 2025 - Breadcrumb Home Training and Education WebM&M: Case Studies WebM&M Case Submission PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential …

447. Caution, Interrupted | PSNet
     psnet.ahrq.gov/web-mm/caution-interrupted
     October 01, 2016 - It illustrates how the "messy details" of technical work—those factors investigators would usually like … The messy details: insights from technical work studies in health care.

448. Procedure Complications – Who is Responsible for Follow up? | PSNet
     psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
     July 31, 2023 - This handoff needs to include documentation of details of the procedure, size of the defect, confidence … arise, the proceduralist should be designated as the main point of contact communicating procedural details

449. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33571/psn-pdf
     March 15, 2025 - Reporting Patient Safety Events March 15, 2025 Reporting Patient Safety Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/reporting-patient-safety-events PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in th…

450. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49872/psn-pdf
     August 08, 2019 - Spinal Epidural Abscess August 8, 2019 Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spinal-epidural-abscess The Case A 30-year-old woman with a history of prior spine surgery presented to the emergency department with a few days of progressive low back pain. She…

451. FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework. | PSNet
     psnet.ahrq.gov/issue/fdasia-health-it-report-proposed-strategy-and-recommendations-risk-based-framework
     June 29, 2016 - Government Resource FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework. Citation Text: FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework. Washington, DC: Office of the National Coordinator for Health Informati…

452. Monitoring patient safety in health care: building the case for surrogate measures. | PSNet
     psnet.ahrq.gov/issue/monitoring-patient-safety-health-care-building-case-surrogate-measures
     June 23, 2009 - Commentary Monitoring patient safety in health care: building the case for surrogate measures. Citation Text: Gaynes RP, Platt R. Monitoring patient safety in health care: building the case for surrogate measures. Jt Comm J Qual Patient Saf. 2006;32(2):95-101. Copy Citation Forma…

453. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39066/psn-pdf
     October 28, 2021 - Hospital Performance Report. October 28, 2021 Trenton, NJ: New Jersey Department of Health and Senior Services. https://psnet.ahrq.gov/issue/hospital-performance-report Detailing results of an error reporting initiative in New Jersey, these reports explain how consumers can use this information and provides tips f…

454. Building Safety Culture and Strengthening Hospital Safety Systems | PSNet
     psnet.ahrq.gov/training-catalog/building-safety-culture-and-strengthening-hospital-safety-systems
     July 07, 2025 - Building Safety Culture and Strengthening Hospital Safety Systems Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization Hospital Quality Institute E…

455. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/860399/psn-pdf
     January 24, 2024 - Best Practices for Administering SOPS Surveys. January 10, 2024 Agency for Healthcare Research and Quality. January 24, 2024. https://psnet.ahrq.gov/issue/best-practices-administering-sops-surveys Patient safety culture survey projects can yield important learnings if done correctly. The webinar detailed best prac…

456. Missing clinical and behavioral health data in a large electronic health record (EHR) system. | PSNet
     psnet.ahrq.gov/issue/missing-clinical-and-behavioral-health-data-large-electronic-health-record-ehr-system
     July 19, 2023 - Study Missing clinical and behavioral health data in a large electronic health record (EHR) system. Citation Text: Madden JM, Lakoma MD, Rusinak D, et al. Missing clinical and behavioral health data in a large electronic health record (EHR) system. J Am Med Info Asso. 2016;23(6):1143-114…

457. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38729/psn-pdf
     April 15, 2019 - CHPSO. April 15, 2019 1215 K Street, Suite 800, Sacramento, CA 95814. https://psnet.ahrq.gov/issue/chpso This Website offers tools, a newsletter focusing on lessons learned from error reports, a set of specialized checklists, and a detailed resource collection to support patient safety organization (PSO) efforts i…

458. Reducing warfarin medication interactions: an interrupted time series evaluation. | PSNet
     psnet.ahrq.gov/issue/reducing-warfarin-medication-interactions-interrupted-time-series-evaluation
     May 27, 2011 - Study Reducing warfarin medication interactions: an interrupted time series evaluation. Citation Text: Feldstein AC, Smith DH, Perrin N, et al. Reducing warfarin medication interactions: an interrupted time series evaluation. Arch Intern Med. 2006;166(9):1009-15. Copy Citation Fo…

459. HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. | PSNet
     psnet.ahrq.gov/issue/hhs-guide-clinicians-appropriate-dosage-reduction-or-discontinuation-long-term-opioid
     October 15, 2008 - Book/Report HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. Citation Text: HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. HHS Guide for Clinicians on the App…

460. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50611/psn-pdf
     October 30, 2019 - though the clinicians in this case did what they should have done, the pharmacy could not see critical details … are often multiple opportunities for information "voltage drops"—in this case resulting in loss of details