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psnet.ahrq.gov/node/49532/psn-pdf
March 15, 2007 - This decision making
represented the wrong approach in this setting, an example of a rule-based error … effectively than those who understand neither the context nor the orders.(1,2,9
) The Figure shows an example … Example Insulin Protocol. (Reprinted with permission of Richard Hellman, MD.)
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psnet.ahrq.gov/node/33741/psn-pdf
November 01, 2012 - In patients with suspected pneumonia, for example, one evidence-based approach filters through
scores … Pneumonia is far from the only example of situations in which physical findings have stunning accuracy … For example, the interobserver agreement for most physical
examination findings is no different than
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psnet.ahrq.gov/node/49520/psn-pdf
September 01, 2006 - achieved.(4) Similar issues arise when a patient with a DNR order undergoes conscious sedation, for
example … For example, a patient might require mechanical ventilation or
vasopressors for longer than anticipated … For example, drugs to support blood pressure
and measures to maintain breathing are used in the operating
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psnet.ahrq.gov/node/37873/psn-pdf
June 16, 2009 - Dropping the baton: a qualitative analysis of failures
during the transition from emergency department to
inpatient care.
June 16, 2009
Horwitz LI, Meredith T, Schuur JD, et al. Dropping the baton: a qualitative analysis of failures during the
transition from emergency department to inpatient care. Ann Emerg Med. …
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psnet.ahrq.gov/node/36044/psn-pdf
April 27, 2010 - Expected and unanticipated consequences of the quality
and information technology revolutions.
April 27, 2010
Wachter R. Expected and unanticipated consequences of the quality and information technology
revolutions. JAMA. 2006;295(23):2780-3.
https://psnet.ahrq.gov/issue/expected-and-unanticipated-consequences-qua…
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psnet.ahrq.gov/issue/clinician-directed-performance-improvement-moving-beyond-externally-mandated-metrics
July 10, 2008 - rapid assessment procedures for implementation research using a team-based approach to analysis: a case example
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - procedures require complex teamwork among anesthesiologists, nurses, and a variety of specialists
For example … that operate in hazardous conditions but have fewer than their fair share of adverse events
Example
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psnet.ahrq.gov/node/38981/psn-pdf
September 30, 2009 - alerts were accepted nearly half the time, and
alerts were generally rejected for valid reasons (for example
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psnet.ahrq.gov/node/39790/psn-pdf
March 21, 2017 - For example, diagnostic errors were frequently cited in
malpractice cases, but executive walk rounds
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psnet.ahrq.gov/node/40586/psn-pdf
March 21, 2017 - pharmacy review of the dashboard provided a vehicle to prevent
medication errors or optimize therapy; for example
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psnet.ahrq.gov/node/42067/psn-pdf
March 18, 2013 - For example, only 6 of 16 included studies considered
administration of a drug at the wrong time to
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psnet.ahrq.gov/node/45156/psn-pdf
June 22, 2017 - were informal and related to difficulty using the
software or to preserve professional roles (for example
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psnet.ahrq.gov/node/45231/psn-pdf
February 14, 2017 - This study is an important example of the need to
rigorously evaluate safety interventions, even those
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psnet.ahrq.gov/node/39947/psn-pdf
July 03, 2014 - An accompanying editorial lauds this study as an example of how to conduct a rigorous, evidence-based
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psnet.ahrq.gov/node/46424/psn-pdf
March 20, 2018 - This study is a rigorous example of how trigger tools can detect safety
hazards and improve timely cancer
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psnet.ahrq.gov/node/47238/psn-pdf
October 13, 2018 - One such example is screening for lung cancer using low-dose computed tomography
(LDCT), which may benefit
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psnet.ahrq.gov/node/35979/psn-pdf
September 17, 2010 - They provide a case-type example
of their suggested process to illustrate their framework.
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psnet.ahrq.gov/node/42548/psn-pdf
December 29, 2014 - The studies had varying definitions of adverse events; for example, some did not include
geriatric syndromes
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psnet.ahrq.gov/node/42361/psn-pdf
September 19, 2013 - While patients were observed engaging in safety behaviors—for
example, questioning the dose of a new
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psnet.ahrq.gov/node/45190/psn-pdf
February 15, 2017 - For example, prior studies have postulated that a weekend effect
exists for patients with acute stroke