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Total Results: 1,779 records

Showing results for "discussion".

61. Medical error: the second victim. | PSNet
    psnet.ahrq.gov/issue/medical-error-second-victim
    March 23, 2011 - innovative approaches for supporting second victims, primarily through encouraging debriefing and open discussion

62. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. | PSNet
    psnet.ahrq.gov/issue/what-can-hospitalized-patients-tell-us-about-adverse-events-learning-patient-reported
    June 29, 2011 - Discussion includes detailed analysis of the reported events and comparison to those noted in the medical

63. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. | PSNet
    psnet.ahrq.gov/issue/using-six-sigma-reduce-medication-errors-home-delivery-pharmacy-service
    November 18, 2015 - Discussion includes a process map of 13 identified indicators that contribute to medication errors and

64. Analysis of Australian newspaper coverage of medication errors. | PSNet
    psnet.ahrq.gov/issue/analysis-australian-newspaper-coverage-medication-errors
    February 15, 2012 - errors in Australian newspapers and found that most articles simply reported on errors with little discussion

65. Ambiguity and workarounds as contributors to medical error. | PSNet
    psnet.ahrq.gov/issue/ambiguity-and-workarounds-contributors-medical-error
    December 23, 2008 - Examples from health care settings are included as well as discussion of case studies previously published

66. Partnering to prevent falls: using a multimodal multidisciplinary team. | PSNet
    psnet.ahrq.gov/issue/partnering-prevent-falls-using-multimodal-multidisciplinary-team
    June 22, 2010 - describes an initiative that reduced falls at a large health care system and highlights a weekly discussion

67. Improving patient care. The cognitive psychology of missed diagnoses. | PSNet
    psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses
    October 03, 2012 - Discussion offers strategies to overcome these diagnostic shortcomings and methods to combat natural

68. Cognitive errors in diagnosis: instantiation, classification, and consequences. | PSNet
    psnet.ahrq.gov/issue/cognitive-errors-diagnosis-instantiation-classification-and-consequences
    June 21, 2016 - Discussion includes detailed examples of each cognitive error type to better illustrate the results,

69. Can we make postoperative patient handovers safer? A systematic review of the literature. | PSNet
    psnet.ahrq.gov/issue/can-we-make-postoperative-patient-handovers-safer-systematic-review-literature
    June 10, 2015 - processes, completing urgent clinical tasks prior to information transfer, allowing patient-specific discussion

70. What is accountability in health care? | PSNet
    psnet.ahrq.gov/issue/what-accountability-health-care
    April 19, 2013 - The discussion begins with explanations of the loci, domains, and procedures of accountability.

71. The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. | PSNet
    psnet.ahrq.gov/issue/challenger-launch-decision-risky-technology-culture-and-deviance-nasa
    November 18, 2015 - worked in a health care organization in which a prominent, adverse event has occurred will find the discussion

72. Surgeon perception and attitude towards the moral imperative of institutionally addressing second-victim syndrome in surgery. | PSNet
    psnet.ahrq.gov/issue/surgeon-perception-and-attitude-towards-moral-imperative-institutionally-addressing-second
    March 24, 2019 - Additionally, discussion and review of adverse events must remain confidential, privileged, and inadmissible

73. Applicability of Healthcare Failure Mode and Effects Analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments. | PSNet
    psnet.ahrq.gov/issue/applicability-healthcare-failure-mode-and-effects-analysis-healthcare-epidemiology-evaluation
    October 19, 2022 - Discussion focuses on creating an initial process flow diagram and how information obtained through interviews

74. The Veterans Affairs root cause analysis system in action. | PSNet
    psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action
    June 22, 2022 - Discussion includes background into VA patient safety programs and the role NCPS plays in providing the

75. The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care.  | PSNet
    psnet.ahrq.gov/issue/critical-care-safety-study-incidence-and-nature-adverse-events-and-serious-medical-errors
    July 15, 2020 - Discussion provides details of the clinical patient characteristics, the range in severity of incidents

76. Accountability in Patient Safety | PSNet
    psnet.ahrq.gov/perspective/accountability-patient-safety
    January 01, 2018 - years of the safety movement and the need for individual accountability has been a subject of robust discussion … safety world has largely embraced the concept of a just culture for many years , this past year saw the discussion

77. The Future of Patient and Family Engagement in Quality and Patient Safety. | PSNet
    psnet.ahrq.gov/issue/future-patient-and-family-engagement-quality-and-patient-safety
    February 24, 2025 - October 9, 2024 Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare

78. Anesthetic mishaps: breaking the chain of accident evolution. | PSNet
    psnet.ahrq.gov/issue/anesthetic-mishaps-breaking-chain-accident-evolution
    April 08, 2011 - The discussion continues by contrasting incidents and accidents and the cognitive processes involved

79. The practice of respect in the ICU. | PSNet
    psnet.ahrq.gov/issue/practice-respect-icu
    August 09, 2018 - This commentary explores the results of a multidisciplinary discussion on the intersection of " respect

80. Patient safety concerns arising from test results that return after hospital discharge. | PSNet
    psnet.ahrq.gov/issue/patient-safety-concerns-arising-test-results-return-after-hospital-discharge
    January 17, 2012 - Discussion also includes survey findings from inpatient providers, which demonstrated poor awareness