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Showing results for "examples".

  1. First, Do No Harm Part 1: A Case Study of Systems Failure. | PSNet

    psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure
    September 07, 2022 - explorations of teamwork, hand-offs, communication skills, and managing the authority gradient provide rich examples

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33935/psn-pdf
    February 05, 2018 - authors describe the incidence, severity, and preventability of reported events along with specific examples

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34953/psn-pdf
    February 03, 2011 - Numerous examples are provided throughout the article.

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46357/psn-pdf
    May 17, 2018 - This commentary uses case examples to illustrate how incorrect or incomplete labeling can affect care

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37610/psn-pdf
    June 16, 2011 - This article presents examples (primarily from outside health care) to illustrate these concepts and

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35312/psn-pdf
    January 02, 2017 - Drawing from more than 7200 wrong administration technique errors, a number of true case examples are

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45021/psn-pdf
    April 06, 2016 - Staffordshire NHS Foundation Trust inquiry and the Veterans Affairs health system investigation as examples

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74112/psn-pdf
    April 14, 2017 - segregation, healthcare quality and access, discriminatory incarceration) and provides intersectoral examples

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46996/psn-pdf
    May 23, 2018 - The authors describe their multimodal educational approach and provide examples of fellow-led projects

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34812/psn-pdf
    March 05, 2008 - Case examples are included to illustrate the mechanics of the technique, in the context of creating

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35802/psn-pdf
    January 02, 2017 - The author also provides case examples for reconciliation errors at admission, transfer of care, and

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34803/psn-pdf
    January 05, 2017 - Discussion includes a description of the RCA system employed, examples of events analyzed, and an informative

  13. AHRQ Patient Safety YouTube Channel. | PSNet

    psnet.ahrq.gov/issue/ahrq-patient-safety-youtube-channel
    December 24, 2008 - Each set of videos provides examples of learning tactics to address the needs of individual learners

  14. Cognitive bias in clinical medicine. | PSNet

    psnet.ahrq.gov/issue/cognitive-bias-clinical-medicine
    February 20, 2019 - This commentary reviews examples of bias that commonly occur in medical practice and describes debiasing

  15. Medical errors arising from outsourcing laboratory and radiology services. | PSNet

    psnet.ahrq.gov/issue/medical-errors-arising-outsourcing-laboratory-and-radiology-services
    October 19, 2022 - This study gives examples of several diagnostic errors attributable at least in part to suboptimal communication

  16. Preparing challenging medications for barcode scanning. | PSNet

    psnet.ahrq.gov/issue/preparing-challenging-medications-barcode-scanning
    October 19, 2022 - This commentary draws from examples such as preparation of insulin and use of ampules to illustrate

  17. Medical simulation gets real. | PSNet

    psnet.ahrq.gov/issue/medical-simulation-gets-real
    June 14, 2023 - This news article reports on the growth of simulation as a teaching tool and describes several examples

  18. Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. Final Report | PSNet

    psnet.ahrq.gov/issue/improving-diagnostic-quality-and-safetyreducing-diagnostic-error-measurement-considerations
    March 25, 2020 - findings; communication failures; information overload; and dismissed patients) reflecting high priority examples

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42341/psn-pdf
    June 19, 2013 - The article includes illustrative examples of both individual and collective workarounds, as well as

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34642/psn-pdf
    June 24, 2015 - They use case examples to illustrate specific incidents and demonstrate the utility of a systems approach
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