-
psnet.ahrq.gov/node/43644/psn-pdf
April 22, 2015 - A past AHRQ
WebM&M perspective discussed a widely-publicized incident involving a patient who died due
-
psnet.ahrq.gov/node/34075/psn-pdf
December 23, 2008 - Another related past study discussed patients' and physicians' attitudes regarding the
disclosure of
-
psnet.ahrq.gov/node/35934/psn-pdf
February 24, 2011 - A past study discussed one of these methods, Morbidity and Mortality Conferences, as
a place to discuss
-
psnet.ahrq.gov/node/38491/psn-pdf
January 31, 2011 - An AHRQ WebM&M perspective discussed cognitive biases that
lead to diagnostic error.
-
psnet.ahrq.gov/node/34993/psn-pdf
June 22, 2009 - Each of these barriers is discussed with thoughtful perspective on both
the associated historical and
-
psnet.ahrq.gov/node/45399/psn-pdf
November 01, 2017 - also
expressed concern about the greater number of handoffs, echoing the ongoing duty-hours debate
discussed
-
psnet.ahrq.gov/node/46318/psn-pdf
August 02, 2017 - Bryan Sexton, discussed resilience, burnout, and safety culture.
-
psnet.ahrq.gov/node/47356/psn-pdf
September 05, 2018 - A past WebM&M commentary discussed a task interruption due
to texting.
-
psnet.ahrq.gov/node/45967/psn-pdf
July 05, 2017 - A recent Annual Perspective discussed ongoing problems
with the root cause analysis process and described
-
psnet.ahrq.gov/node/39895/psn-pdf
September 21, 2011 - Mark Chassin, the
president of the Joint Commission, discussed the organization's approach to improving
-
psnet.ahrq.gov/node/34774/psn-pdf
June 02, 2010 - and dangers inherent in medical progress,
from adverse drug reactions to unnecessary surgery, are discussed
-
psnet.ahrq.gov/node/38543/psn-pdf
April 27, 2010 - Two cases of preventable
readmissions are discussed in this AHRQ WebM&M commentary.
-
psnet.ahrq.gov/node/45900/psn-pdf
June 07, 2017 - An error associated with a mislabeled blood sample is discussed in a past WebM&M commentary.
-
psnet.ahrq.gov/node/41068/psn-pdf
September 29, 2017 - A case of a misunderstood verbal order that led to a serious error is discussed in this
AHRQ WebM&M
-
psnet.ahrq.gov/node/44818/psn-pdf
February 24, 2018 - A PSNet perspective on
the business case for patient safety discussed health care–associated infections
-
psnet.ahrq.gov/node/34013/psn-pdf
December 22, 2008 - While the intensive care unit represents the contextual
background for this review, a past study also discussed
-
psnet.ahrq.gov/node/38940/psn-pdf
November 25, 2009 - A case of an inadvertent medication overdose in an infant due to
inadequate parental education is discussed
-
psnet.ahrq.gov/node/44618/psn-pdf
February 10, 2016 - A prior WebM&M commentary
discussed tall man lettering as one strategy for improving the safety of look-alike
-
digital.ahrq.gov/sites/default/files/docs/citation/r13hs024833-gill-final-report-2017.pdf
January 01, 2017 - In the evening, an invite-only talk for workgroup
participants offered over dinner discussed the relationship … Affordances and
deficiencies of various VR technologies were discussed for a variety of use cases. … An overview
of research findings were discussed from the Hank Virtual Environments Laboratory on how … In the afternoon, ideas that were discussed within each
breakout group of six were presented to the … This suggestion should be discussed prior to implementation; one of
the challenges we faced in structuring
-
cds.ahrq.gov/sites/default/files/workgroups/221/feb-2017-cholesterol-wg-notes.docx
January 01, 2017 - Allergies are very rare and side effects can usually be discussed and worked through with the patient … and debilitating side effects, such as myalgia, may also be considered.
· Interventions:
· WG members discussed … Discuss Statin Therapy for the Prevention and Treatment of CVD eCQM/CDS Artifact
Not discussed.