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psnet.ahrq.gov/node/838220/psn-pdf
September 27, 2019 - For example, primary care providers can improve diagnostic safety
through the use of relationship-based … For example, if a patient receives the correct
medications for a particular condition (effectiveness … care, such as access and social
and environmental factors that may
impact health outcomes; for
example … For example, behavioral health programs that address
substance misuse and mental health conditions might … minority racial and ethnic groups.31
Identifying the areas in which primary care has the most impact—for example
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psnet.ahrq.gov/node/33605/psn-pdf
March 12, 2021 - For example, the epinephrine auto injector (EpiPen) for treatment of anaphylaxis is provided
in a ready-to-use … As an example, one type of eye drops (prostaglandins) has a
turquoise cap on the bottle, across all … Users may encounter
blockades in the BCMA workflow, for example, when the patient's arm band is not … For example, some patient controlled analgesia pumps (PCAs) can be linked to an End Tidal CO2 monitor
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psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy
November 25, 2020 - clinical reasoning by individual physicians sits at the intersection of science and art in medicine, for example … One example relevant to this case is referred to as “framing bias,” which is a tendency to be influenced … One pervasive example was communication among the various providers. … , breaking down silos, and involvement of patients in decision-making. 7 Better communication, for example
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psnet.ahrq.gov/node/45083/psn-pdf
July 18, 2016 - commentary emphasizes the need for valid patient
safety measures and mentions the Surgeon Scorecard as an example
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psnet.ahrq.gov/node/42748/psn-pdf
November 20, 2013 - However, the utility of the written signout varied widely despite use of
a template—for example, the
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psnet.ahrq.gov/node/43263/psn-pdf
July 16, 2014 - For example, the official
investigation of the Mid-Staffordshire NHS Foundation Trust in the United
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psnet.ahrq.gov/node/42711/psn-pdf
October 31, 2014 - For example, incorrect transcription of an order could then lead to a medication administration
error
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psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - procedure performed at the correct site but at the wrong level or part of the operative field, for example … For example, the North American Spine Society has recommended that in addition to the Universal Protocol … For example, a change in hospital policy requiring imaging to be present in the operating suite prior … Definitions and Examples of Wrong-Site Surgeries.( 2 ) Type Definition Example
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psnet.ahrq.gov/node/33658/psn-pdf
October 01, 2007 - For example, when
hand hygiene compliance rates are just 60%, how do we get people to be compliant? … for
example, inadvertently going faster than the speed limit. … Just on that example, where do you draw the line?
DM: I think a hospital? … Another example is workers'
compensation systems?
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psnet.ahrq.gov/node/33859/psn-pdf
June 01, 2018 - Take for
example pediatric safety and quality around appendicitis—if a patient comes in with physical … Let me give you an example of
how that might be beneficial. … For example, if you
are scanning the heart and capturing an apical four-chamber view, the ultrasound … For
example, if they cannot get a good image, they should not try to interpret the image. … Ultrasound is a fabulous teaching tool to explain
to patients why, for example, they have to take three
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psnet.ahrq.gov/perspective/telemedicine-and-patient-safety
September 01, 2016 - For example, a synthesis of evidence from 15 systematic reviews published between 2003 and 2013 demonstrated … As one example, a number of studies have shown that medication errors can be significantly reduced by … For example, even telemedicine advocates would not argue that patients with chest pain should be managed … For example, what is the appropriate use of the telephone as an intervention system versus video, and … Another key thing is that, if you take the example of stroke care, we are finding the volume that telehealth
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psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md
September 01, 2016 - For example, what is the appropriate use of the telephone as an intervention system versus video, and … Another key thing is that, if you take the example of stroke care, we are finding the volume that telehealth … For example, a synthesis of evidence from 15 systematic reviews published between 2003 and 2013 demonstrated … As one example, a number of studies have shown that medication errors can be significantly reduced by … For example, even telemedicine advocates would not argue that patients with chest pain should be managed
-
psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
October 01, 2007 - Policies that require punishment for errors, for example, won't work. … If your organization's priority is reducing harm related to misidentification of patients, for example … 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?
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psnet.ahrq.gov/node/49694/psn-pdf
October 01, 2013 - The Commentary
This case is an unusual example of a wrong patient error, but similar errors have occurred … For example, in
a hospital in the United Kingdom, a nurse, intending to call the family of a dying patient … For example,
blood unit bar coding was shown to prevent 11.2 misidentification transfusion errors per
-
psnet.ahrq.gov/node/33857/psn-pdf
July 01, 2012 - We were thinking, for example, about what innovative future NIH [National Institutes of Health] grants … I'll give you one example that has given me faith, which is actually a low-tech example of what I think … That to me was a magical example of what this looks like.
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psnet.ahrq.gov/node/34729/psn-pdf
October 31, 2016 - Set Phasers on Stun: And Other True Tales of Design,
Technology, and Human Error, Second Edition.
October 31, 2016
Casey SM. Santa Barbara, CA: Aegean; 1998. ISBN 9780963617880.
https://psnet.ahrq.gov/issue/set-phasers-stun-and-other-true-tales-design-technology-and-human-error-
second-edition
This book introduce…
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psnet.ahrq.gov/issue/driving-improvement-patient-care-lessons-toyota
September 24, 2016 - September 24, 2010
Framing patient safety initiatives: working model and case example
-
psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
March 01, 2017 - RW : Can you give an example of a piece of forbidden knowledge? … For example, junior doctors are supposed to be given quiet time to complete their notes, but they never … What I'm seeing, for example, is the notion of error increasingly receding and increasingly a focus on … I don't fully agree with—but that move is generally positive in that there's much to learn from the example … For example, with the use of routine beta-blockers in surgery, where that technical intervention just
-
psnet.ahrq.gov/node/33712/psn-pdf
June 01, 2011 - RW: Can you give us your favorite example or two from outside of health care? … universal law: automobile seat belts actually do reduce deaths and injuries, although the
record of, for example … patient safety
and health care issues, and it's one that also appears in many other safety contexts, for example … This seems to have been the case, for example, in the federal Minerals
Management Service.
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psnet.ahrq.gov/node/33759/psn-pdf
October 01, 2012 - scope, and it has been successfully
applied without complex technical or electronic resources.(4) For example … The field of diagnostic error and performance is another
example of one of these emerging subject areas … One example of this linkage is demonstrated through the research program, "Proactive Risk Assessment … Further implementation of TeamSTEPPS in
medical offices is underway and demonstrates another example