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Showing results for "failures".

  1. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings | PSNet

    psnet.ahrq.gov/web-mm/multiple-missed-opportunities-suicide-risk-assessment-emergency-and-primary-care-settings
    May 26, 2021 - Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings Citation Text: Erb JL, Shah SB, Schiff G. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867805/psn-pdf
    February 26, 2025 - have noted is that variation in how well hospitals prevent falls or pressure injuries suggests that failures

  3. Removing Insult from Injury—Disclosing Adverse Events | PSNet

    psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
    February 01, 2006 - that they can report their errors so risk management can look into the organization's latent system failures

  4. Difficult Encounters: A CMO and CNO Respond | PSNet

    psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
    March 01, 2018 - 12, 2019 Failure to debrief after critical events in anesthesia is associated with failures

  5. In Conversation with…John Banja, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd
    February 01, 2006 - that they can report their errors so risk management can look into the organization's latent system failures

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73153/psn-pdf
    April 28, 2021 - The second case illustrates the consequences of process failures when multiple errors occur, undesigned

  7. In Conversation With… Maureen Bisognano | PSNet

    psnet.ahrq.gov/perspective/conversation-maureen-bisognano
    February 26, 2025 - Those failures then add up.

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33857/psn-pdf
    July 01, 2012 - more and more to consumer-mediated exchange as a way to get past those disincentives, those market failures

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33789/psn-pdf
    August 01, 2015 - pecking order relative to medication errors, wrong-site procedures, and/or communication and teamwork failures

  10. In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet

    psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
    September 24, 2024 - Combine this prevention strategy with a spirit of continuous learning from successes and failures, and

  11. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit | PSNet

    psnet.ahrq.gov/perspective/quality-and-safety-challenges-critical-care-preventing-and-treating-delirium-intensive
    December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit Eduard E. Vasilevskis, MD; E. Wesley Ely, MD, MPH; Robert S. Dittus, MD, MPH | December 1, 2012  Also Read a Conversation View more articles from the same authors. …

  12. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
    January 01, 2023 - A systematic review of failures in handoff communication during intrahospital transfers.

  13. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet

    psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
    August 01, 2012 - A systematic review of failures in handoff communication during intrahospital transfers.

  14. New Insights on Safety and Health IT | PSNet

    psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
    August 01, 2015 - pecking order relative to medication errors, wrong-site procedures, and/or communication and teamwork failures

  15. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.72_slideshow.ppt
    September 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case September 2004 Poor Prognosis? Source and Credits This presentation is based on the September 2004 AHRQ WebM&M Spotlight Case in Surgery See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Elizabeth B. Lamont, M…

  16. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.341_slideshow.ppt
    March 01, 2015 - PowerPoint Presentation Spotlight Two Wrongs Don't Make a Right (Kidney) This presentation is based on the March 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John G. DeVine, MD, Professor of Orthopaedic Surgery, Medical College of Georgia Ed…

  17. Teamwork Training | PSNet

    psnet.ahrq.gov/primer/teamwork-training
    September 15, 2024 - Teamwork Training Citation Text: Teamwork Training. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33578/psn-pdf
    September 15, 2024 - Human Factors Engineering September 15, 2024 Human Factors Engineering. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/human-factors-engineering PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safe…

  19. Rapid Response Systems | PSNet

    psnet.ahrq.gov/primer/rapid-response-systems
    July 18, 2024 - Rapid Response Systems Citation Text: Rapid Response Systems. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33588/psn-pdf
    March 15, 2025 - Second Victims: Support for Clinicians Involved in Errors and Adverse Events March 15, 2025 Second Victims: Support for Clinicians Involved in Errors and Adverse Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events PSNet primers are regu…
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