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Showing results for "experiences".

4401. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33830/psn-pdf
      March 22, 2016 - Measuring and Responding to Deaths From Medical Errors March 22, 2016 Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors Annual Perspective 2016 The Prevalence of Deaths Due to Preventable Adve…

4402. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38810/psn-pdf
      July 22, 2009 - When doctors make mistakes. July 22, 2009 Chen PW. https://psnet.ahrq.gov/issue/when-doctors-make-mistakes-1 This column shares one physician's experience with the deterioration of a colleague's practice after involvement in error. The piece highlights the need for effective support of physicians-in-training to ma…

4403. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35428/psn-pdf
      January 02, 2017 - An interview with Lucian Leape. January 2, 2017 Schyve PM. An Interview with Lucian Leape. Jt Comm J Qual Patient Saf. 2016;30(12):653-658. doi:10.1016/s1549-3741(04)30076-6. https://psnet.ahrq.gov/issue/interview-lucian-leape This interview with Dr. Leape, a 2004 Eisenberg Award winner, draws on his extensive exp…

4404. Endometriosis: A Common and Commonly Missed and Delayed Diagnosis | PSNet
      psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis
      May 26, 2021 - Women’s experiences of endometriosis: a systematic review and synthesis of qualitative research.

4405. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41351/psn-pdf
      June 27, 2018 - Noah's story: please listen. June 27, 2018 Lord T. Patient Saf Qual Healthc. March/April 2012;9:38-41,44. https://psnet.ahrq.gov/issue/noahs-story-please-listen This article details how miscommunication and lack of patient-centered care contributed to errors that led to the death of a child. https://psnet.ahrq.go…

4406. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36206/psn-pdf
      September 30, 2010 - Reducing medication errors by using applied technology. September 30, 2010 Caesar BR, Hutchinson B. Reducing medication errors by using applied technology. Nursing (Brux). 2006;36(8):24-25. https://psnet.ahrq.gov/issue/reducing-medication-errors-using-applied-technology The authors describe their experience in imp…

4407. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33973/psn-pdf
      December 03, 2007 - To err is human; the need for trauma support is, too. December 3, 2007 Kenney LK, van Pelt RA. Patient Safety Quality Healthcare. January/February 2005. https://psnet.ahrq.gov/issue/err-human-need-trauma-support-too This article relates the story of an adverse event from the perspective of both patient and physicia…

4408. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38000/psn-pdf
      August 03, 2009 - The competitive imperative of learning. August 3, 2009 Edmondson A. The competitive imperative of learning. Harv Bus Rev. 2008;86(7-8):60-7, 160. https://psnet.ahrq.gov/issue/competitive-imperative-learning This article draws on experience analyzing team behavior in hospitals to discuss how learning processes can …

4409. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38991/psn-pdf
      September 30, 2009 - Why don't doctors wash their hands more? September 30, 2009 Chen PW. https://psnet.ahrq.gov/issue/why-dont-doctors-wash-their-hands-more The author uses personal experience to explain how sterile technique is strict in the operating room. The column highlights the Joint Commission effort to improve hand hygiene co…

4410. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40879/psn-pdf
      May 27, 2015 - Optimizing patient safety during hemodialysis. May 27, 2015 Himmelfarb J. Optimizing patient safety during hemodialysis. JAMA. 2011;306(15):1707-8. doi:10.1001/jama.2011.1507. https://psnet.ahrq.gov/issue/optimizing-patient-safety-during-hemodialysis This editorial discusses hemodialysis safety in the context of a…

4411. Diagnostic uncertainty among critically ill children admitted to the PICU: a multicenter study. | PSNet
      psnet.ahrq.gov/issue/diagnostic-uncertainty-among-critically-ill-children-admitted-picu-multicenter-study
      June 14, 2023 - Study Diagnostic uncertainty among critically ill children admitted to the PICU: a multicenter study. Citation Text: Cifra CL, Custer JW, Smith CM, et al. Diagnostic uncertainty among critically ill children admitted to the PICU: a multicenter study. Crit Care Med. 2025;53(2):e294-e307. …

4412. Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic. | PSNet
      psnet.ahrq.gov/issue/using-event-reports-real-time-identify-and-mitigate-patient-safety-concerns-during-covid-19
      March 23, 2022 - Commentary Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic. Citation Text: Kasda EM, Robson C, Saunders J, et al. Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic.…

4413. Going to the COVID-19 Gemba: using observation and high reliability strategies to achieve safety in a time of crisis. | PSNet
      psnet.ahrq.gov/issue/going-covid-19-gemba-using-observation-and-high-reliability-strategies-achieve-safety-time
      May 12, 2021 - Commentary Going to the COVID-19 Gemba: using observation and high reliability strategies to achieve safety in a time of crisis. Citation Text: Thull-Freedman J, Mondoux S, Stang A, et al. Going to the COVID-19 Gemba: Using observation and high reliability strategies to achieve safety in…

4414. Patient safety in emergency departments: a problem for health care systems? An international survey. | PSNet
      psnet.ahrq.gov/issue/patient-safety-emergency-departments-problem-health-care-systems-international-survey
      February 26, 2020 - Study Patient safety in emergency departments: a problem for health care systems? An international survey. Citation Text: Petrino R, Tuunainen E, Bruzzone G, et al. Patient safety in emergency departments: a problem for health care systems? An international survey. Eur J Emerg Med. 2023;…

4415. Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients. | PSNet
      psnet.ahrq.gov/issue/association-coworker-reports-about-unprofessional-behavior-surgeons-surgical-complications
      June 27, 2018 - Study Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients. Citation Text: Cooper WO, Spain DA, Guillamondegui O, et al. Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complication…

4416. COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought. | PSNet
      psnet.ahrq.gov/issue/covid-19-crisis-safe-reopening-simulation-centres-and-new-normal-food-thought
      September 30, 2020 - Commentary COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought. Citation Text: Ingrassia PL, Capogna G, Diaz-Navarro C, et al. COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought. Adv Simul (Lond). 2020;5:13. d…

4417. Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes and Effect Analysis with in situ simulation. | PSNet
      psnet.ahrq.gov/issue/development-rapid-response-capabilities-large-covid-19-alternate-care-site-using-failure
      September 16, 2020 - Commentary Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes and Effect Analysis with in situ simulation. Citation Text: Levy N, Zucco L, Ehrlichman RJ, et al. Development of rapid response capabilities in a large COVID-19 alternate ca…

4418. The impact of COVID-19 response on central line associated bloodstream infections and blood culture contamination rates at a tertiary care center in greater Detroit area. | PSNet
      psnet.ahrq.gov/issue/impact-covid-19-response-central-line-associated-bloodstream-infections-and-blood-culture
      February 07, 2022 - Study The impact of COVID-19 response on central line associated bloodstream infections and blood culture contamination rates at a tertiary care center in greater Detroit area. Citation Text: LeRose J, Sandhu A, Polistico J, et al. The impact of COVID-19 response on central line associat…

4419. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. | PSNet
      psnet.ahrq.gov/issue/some-unintended-consequences-information-technology-health-care-nature-patient-care
      November 18, 2020 - Study Classic Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. Citation Text: Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: t…

4420. Intravenous smart pump drug library compliance: a descriptive study of 44 hospitals. | PSNet
      psnet.ahrq.gov/issue/intravenous-smart-pump-drug-library-compliance-descriptive-study-44-hospitals
      July 31, 2019 - Study Intravenous smart pump drug library compliance: a descriptive study of 44 hospitals. Citation Text: Giuliano KK, Su W-T, Degnan DD, et al. Intravenous Smart Pump Drug Library Compliance: A Descriptive Study of 44 Hospitals. J Patient Saf. 2018;14(4):e76-e82. doi:10.1097/PTS.0000000…