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psnet.ahrq.gov/node/34691/psn-pdf
May 18, 2016 - Using the aviation industry as an example, Leape advances a systems-
based approach to improving patient
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psnet.ahrq.gov/node/40338/psn-pdf
March 23, 2011 - For example, the state of California
mandates certain minimum nurse-to-patient ratios in intensive care
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psnet.ahrq.gov/node/34797/psn-pdf
October 06, 2015 - Though it represents one example, the rich discussion in this article applies to most new
technology
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psnet.ahrq.gov/node/44060/psn-pdf
November 16, 2015 - This tool is an example of the increasingly utilized strategy of engaging
patients in preventing errors
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psnet.ahrq.gov/node/35899/psn-pdf
January 02, 2017 - An example of the actual
policy created for Marion General Hospital's operating room is also included
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psnet.ahrq.gov/node/34780/psn-pdf
March 28, 2005 - adopters, making early
adopter activity observable, trusting and enabling reinvention, and leading by example
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psnet.ahrq.gov/node/39916/psn-pdf
July 02, 2014 - that residents' willingness to fully disclose errors was dependent on social contextual factors (for
example
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psnet.ahrq.gov/node/35817/psn-pdf
July 21, 2010 - They provide a case example with a detailed dialogue between an
attending physician, an intern, and
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psnet.ahrq.gov/node/36470/psn-pdf
September 27, 2010 - For example, rural hospitals placed
less emphasis on the need for sophisticated information technology
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psnet.ahrq.gov/node/44876/psn-pdf
February 10, 2016 - system-failures
The high-profile misdiagnosis of a patient with Ebola in the United States serves as a key example
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psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
September 01, 2005 - Many physicians, for example, have very strong views about various aspects of malpractice reform. … You get some information, for example, about aspects of hospital care and you want to know more, and … used read-backs to ensure that orders have been correctly transmitted) for guidance.( 5 )
A third example … For example, as American Nurses Association president Barbara Blakeney recently described in this space … Examples of Translocational Research in Patient Safety
Strategy
Non–health care example
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psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
November 10, 2015 - Trigger tools are an example of this methodology; an automated trigger is used to identify cases that … whether or not a specific adverse event, such as an adverse drug event (ADE), occurred.( 11-13 ) For example … , an example of a trigger for one type of ADE is, "active prescription for potassium and serum potassium … For example, an "emergency room" trigger automatically gets triggered when a patient has a subsequent … be used to detect and track safety events across large populations of patients over time.( 15 ) One example
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psnet.ahrq.gov/node/49584/psn-pdf
April 01, 2009 - with system barriers—their need to help
patients supersedes HIT protocols.(5) Hence clinicians, for example … For example, there may be more than 20 ways of writing the same patient's name in any one hospital ( … For example, data displayed in the chart are usually without additional identifying information such … hospital had installed the full
EMR in that lab, dermatopathologists could review cases and see, for example … Example of how a hospital might write one patient's name 22 different ways.
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psnet.ahrq.gov/node/34767/psn-pdf
November 28, 2018 - Why Things Bite Back: Technology and the Revenge of
Unintended Consequences.
November 28, 2018
Tenner E. New York, NY: Knopf; 1996. ISBN: 0679425632.
https://psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences
Tenner’s discussions of medical and nonmedical examples provide an e…
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psnet.ahrq.gov/node/850673/psn-pdf
June 14, 2023 - VON is an excellent example for how to integrate family
partnerships within an organization to improve … Bev Johnson: I’ll give you another personal example. … I have a wonderful example right here in Washington, DC. … The other example is with patient and family advisory councils (PFACs). … One more example—during the first week of the pandemic in Canada, senior leaders at Kingston General
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psnet.ahrq.gov/node/867653/psn-pdf
February 26, 2025 - A non-healthcare example is a gas pump. … As an
example, a traditional RCA would often feature large meetings with leadership, the staff involved … For
example, they may start with the action hierarchy or the causation process with the Five Whys. … the RCA2 tools to look at patient emotional harm and address it in more
sustainable ways.2 One last example … For example, a
refrigerator storing vaccines was accidentally left off all weekend and, therefore, all
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psnet.ahrq.gov/node/44672/psn-pdf
October 11, 2017 - The investigators found that IT introduced new
types of errors (for example, choosing the wrong medication
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psnet.ahrq.gov/node/37411/psn-pdf
March 28, 2012 - For example, although most physicians supported full
disclosure of errors to patients, only a minority
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psnet.ahrq.gov/node/36025/psn-pdf
March 28, 2011 - Using a case example, the
authors illustrate how situational awareness can be applied to health care
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psnet.ahrq.gov/node/35497/psn-pdf
June 30, 2011 - The study provides a nice example of how FMEA
techniques analyze high-risk care processes while prioritizing