-
psnet.ahrq.gov/node/38662/psn-pdf
April 12, 2011 - patient-error-preliminary-taxonomy
Preliminary research has found that patient factors may contribute to errors—for example
-
psnet.ahrq.gov/node/35328/psn-pdf
May 19, 2015 - the practical use of health care failure mode and effects analysis (HFMEA) by
presenting a real case example
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psnet.ahrq.gov/node/34998/psn-pdf
June 22, 2009 - Results
include breakdown of the specific factors and adverse events analyzed, including a graphic example
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psnet.ahrq.gov/node/44907/psn-pdf
May 25, 2016 - For example, the
seminal Keystone ICU project combined a checklist with regular data audit and feedback
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psnet.ahrq.gov/node/36947/psn-pdf
September 09, 2011 - A prior AHRQ WebM&M
commentary discusses an example of inadequate warfarin monitoring resulting in adverse
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psnet.ahrq.gov/node/36068/psn-pdf
September 28, 2010 - to physician reporting have been described previously, the authors advocate for
use of their tool (example
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psnet.ahrq.gov/node/60552/psn-pdf
June 03, 2020 - surface area may lead to better protection but at the cost of more difficult
donning or doffing – for example
-
psnet.ahrq.gov/node/72834/psn-pdf
March 10, 2021 - For example, one study found
that during the diagnosis process in the emergency department (ED), 23% … For example, in the development of
advance care planning documentation, one study concluded that interventions … For
example, interdisciplinary bedside rounding approaches bring together clinicians with the goal of … For example, a survey of over 500 OB/GYNs
indicated an opportunity to improve available tools for communicating
-
psnet.ahrq.gov/node/33872/psn-pdf
January 01, 2018 - The acceptance of the concept and consequences of psychological harm is an example of how the patient … For example, a health IT patient
engagement intervention used tablet computers to show patients potentially … This example
speaks to larger interoperability shortcomings that plague EHRs.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
November 01, 2005 - information
Hospitals must determine if these changes introduce new opportunities for errors
Example … CooleyDickinsonReconcilForm.doc
http://www.macoalition.org/Initiatives/RecMeds/CooleyDickinsonReconcilForm.doc
Example … Form (cont.)
http://www.macoalition.org/Initiatives/RecMeds/CaritasNorwoodReconcilForm.doc
More Example
-
psnet.ahrq.gov/node/866621/psn-pdf
August 28, 2024 - One example is to
map a process using the Functional Resilience Analysis Method (FRAM) to understand … been used
in settings such as intensive care, transitions of care, and sepsis management.1
Another example … For example, New York Health and Hospitals pioneered what they call a
success cause analysis, which
-
psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
October 01, 2007 - For example, when hand hygiene compliance rates are just 60%, how do we get people to be compliant? … The human error is inadvertentfor example, inadvertently going faster than the speed limit. … Just on that example, where do you draw the line? … Another example is workers' compensation systemsyou don't sue your employer, but there is a system to … Policies that require punishment for errors, for example, won't work.
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psnet.ahrq.gov/issue/making-business-case-quality-and-safety
January 19, 2022 - April 5, 2017
Framing patient safety initiatives: working model and case example.
-
psnet.ahrq.gov/node/39192/psn-pdf
February 02, 2011 - more than 22,000 hemodialysis patients undergoing percutaneous coronary interventions (PCI) (for
example
-
psnet.ahrq.gov/node/44850/psn-pdf
September 06, 2016 - impact-drug-shortage-medication-errors-and-clinical-outcomes-pediatric-intensive-care-unit
https://psnet.ahrq.gov/issue/impact-drug-shortages-children-cancer-example-mechlorethamine
-
psnet.ahrq.gov/node/42619/psn-pdf
January 23, 2019 - psnet.ahrq.gov/issue/high-reliability-health-care-getting-there-here
Aviation is often cited as an example
-
psnet.ahrq.gov/node/34698/psn-pdf
January 04, 2017 - Care Failure Mode Effects Analysis (HFMEA), is documented in detail, including a complete illustrated
example
-
psnet.ahrq.gov/node/42250/psn-pdf
June 03, 2013 - The article provides an excellent example of
the ongoing monitoring and adaptation required to effectively
-
psnet.ahrq.gov/node/46732/psn-pdf
June 07, 2018 - The authors describe an international example to illustrate how this approach
can be implemented to
-
psnet.ahrq.gov/node/39533/psn-pdf
May 25, 2015 - For example, hospitals where
respondents felt that handoffs and signouts were carried out safely were