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Showing results for "discussions".

361. Medical Mistakes and What Doctors Can Learn From Pilots | PSNet
     psnet.ahrq.gov/training-catalog/medical-mistakes-and-what-doctors-can-learn-pilots
     Medical Mistakes and What Doctors Can Learn From Pilots Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization American Academy of Ophthalmology Even…

362. 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 - Special or Theme Issue The Future of Patient and Family Engagement in Quality and Patient Safety. Citation Text: The Future of Patient and Family Engagement in Quality and Patient Safety. Front Health Serv. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

363. Swiss Cheese Model | PSNet
     psnet.ahrq.gov/taxonomy/term/3460
     April 10, 2025 - Swiss Cheese Model Reason developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. In the model, each slice of cheese represents a safety barrier or precaution relevant to a particular …

364. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-470
     December 31, 2024 - January 15, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, report…

365. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37412/psn-pdf
     December 12, 2007 - The checklist. December 12, 2007 Gawande A. New Yorker. December 10, 2007:86-95. https://psnet.ahrq.gov/issue/checklist This article by bestselling author and surgeon Atul Gawande illustrates the complexity of intensive care and profiles Peter Pronovost, the Johns Hopkins intensivist and safety leader whose effort…

366. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34636/psn-pdf
     June 14, 2011 - The wrong patient. June 14, 2011 Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136(11):826-833. https://psnet.ahrq.gov/issue/wrong-patient This case study describes the events of a patient who underwent an unintended invasive cardiac electrophysiology study. While reviewing the details of the case…

367. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34638/psn-pdf
     December 23, 2008 - What is accountability in health care? December 23, 2008 Emanuel EJ, Emanuel LL. What is accountability in health care? Ann Intern Med. 1996;124(2):229-239. https://psnet.ahrq.gov/issue/what-accountability-health-care This perspective details the concepts surrounding “accountability” in health care. The discussion …

368. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46723/psn-pdf
     April 12, 2019 - Diagnostic assessment of deep learning algorithms for detection of lymph node metastases in women with breast cancer. April 12, 2019 Bejnordi BE, Veta M, van Diest PJ, et al. Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer. JAMA. 2017;318(22):219…

369. Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. | PSNet
     psnet.ahrq.gov/issue/sentinel-event-alert-67-preserving-patient-safety-after-cyberattack
     March 13, 2024 - Sentinel Event Alerts Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. Citation Text: Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. Jt Comm J Qual Patient Saf. 2023;49(12):724-729. doi:10.1016/j.jcjq.2023.07.006. Copy Citation Format…

370. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46349/psn-pdf
     August 16, 2017 - Health Literacy Tools for Providers of Medication Therapy Management. August 16, 2017 Rockville, MD: Agency for Healthcare Research and Quality; July 2017. https://psnet.ahrq.gov/issue/health-literacy-tools-providers-medication-therapy-management Health literacy is important for effective care communications and s…

371. Don't Use That Port: Insert a PICC | PSNet
     psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
     December 22, 2018 - Don't Use That Port: Insert a PICC Citation Text: Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

372. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34650/psn-pdf
     April 21, 2015 - Human error: models and management. April 21, 2015 Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770. https://psnet.ahrq.gov/issue/human-error-models-and-management The author discusses concepts of human error, contrasting the person approach with a system approach in understanding the diff…

373. What medications does your patient take? Enhancing medication safety in the outpatient setting. | PSNet
     psnet.ahrq.gov/issue/what-medications-does-your-patient-take-enhancing-medication-safety-outpatient-setting
     January 08, 2020 - Commentary What medications does your patient take? Enhancing medication safety in the outpatient setting. Citation Text: What medications does your patient take? Enhancing medication safety in the outpatient setting. Institute for Healthcare Improvement; IHI Copy Citation …

374. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867004/psn-pdf
     October 30, 2024 - Critical Radiology Alert Process October 30, 2024 https://psnet.ahrq.gov/innovation/critical-radiology-alert-process Summary Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of unrelated abnormal findings and provides a companion follow-up process, with the goal o…

375. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33606/psn-pdf
     December 15, 2024 - Opioid Safety December 15, 2024 Opioid Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/opioid-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in 2024. Bac…

376. Second Victims: Support for Clinicians Involved in Errors and Adverse Events | PSNet
     psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
     December 15, 2024 - Second Victims: Support for Clinicians Involved in Errors and Adverse Events Citation Text: Second Victims: Support for Clinicians Involved in Errors and Adverse Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cit…

377. Triggers and Trigger Tools | PSNet
     psnet.ahrq.gov/primer/triggers-and-trigger-tools
     September 15, 2024 - Triggers and Trigger Tools Citation Text: Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…

378. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety | PSNet
     psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
     October 01, 2009 - single case later leads to more thoughtful analyses of the safety hazards it illustrates, accompanied by discussions

379. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43342/psn-pdf
     July 16, 2014 - Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool. July 16, 2014 Chapman SM, Fitzsimons J, Davey N, et al. Prevalence and severity of patient harm in a sample of UK- hospitalised children detected by the Paediatric Trigger Tool. BMJ Open. 2014;4…

380. Which End Is Which? | PSNet
     psnet.ahrq.gov/web-mm/which-end-which
     February 09, 2011 - Which End Is Which? Citation Text: Campbell AR. Which End Is Which?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …