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Showing results for "failures".

  1. "We're almost guests in their clinical care": inpatient provider attitudes toward chronic disease management. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/health-information-technology-heart-failure-care/citation/attitudes
    January 01, 2023 - "We're almost guests in their clinical care": inpatient provider attitudes toward chronic disease management. Citation Blecker S, Meisel T, Dickson VV, et al. "We're almost guests in their clinical care": inpatient provider attitudes toward chronic disease management. J Hosp Med 2017 Mar;12(3):162-7.…

  2. Unobtrusive, Actionable Reminders and Performance Feedback Improve Physician Performance on Standardized Quality Measures | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/using-precision-performance-measurement-conduct-focused-quality-improvement-2
    January 01, 2023 - Unobtrusive, Actionable Reminders and Performance Feedback Improve Physician Performance on Standardized Quality Measures Citation AHRQ Health Care Innovations Exchange. Innovation Profile: Unobtrusive, Actionable Reminders and Performance Feedback Improve Physician Performance on Standardized Quality…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837813/psn-pdf
    January 21, 2021 - Recognizing Excellence in Diagnosis. January 21, 2021 The Leapfrog Group. https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise to be successful. This collaborative initiative will initially dev…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60165/psn-pdf
    March 25, 2020 - The threat within: mitigating the risk of medical error. March 25, 2020 Bennett S. The Threat Within: Mitigating The Risk Of Medical Error. Springer International Publishing; 2020. doi:10.1007/978-3-030-23491-1_3. https://psnet.ahrq.gov/issue/threat-within-mitigating-risk-medical-error Despite efforts to protect p…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47966/psn-pdf
    May 29, 2019 - Patient Safety Essentials Toolkit. May 29, 2019 Boston, MA: Institute for Healthcare Improvement; 2019. https://psnet.ahrq.gov/issue/patient-safety-essentials-toolkit This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis, and communication as well as templates to …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72512/psn-pdf
    November 25, 2020 - The untold story of a cyberattack, a hospital and a dying woman. November 25, 2020 Ralston W. Wired Magazine. November 11, 2020. https://psnet.ahrq.gov/issue/untold-story-cyberattack-hospital-and-dying-woman Health information system downtime can affect patient safety. This story discusses a ransomware incide…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44917/psn-pdf
    November 30, 2016 - Canadian Incident Analysis Framework. November 30, 2016 Incident Analysis Collaborating Parties. Edmonton, AB: Canadian Patient Safety Institute; 2012. ISBN: 9781926541440. https://psnet.ahrq.gov/issue/canadian-incident-analysis-framework Performing incident analysis can help organizations understand why adverse e…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41331/psn-pdf
    October 03, 2017 - Leading a highly visible hospital through a serious reportable event. October 3, 2017 Erickson JI. Leading a highly visible hospital through a serious reportable event. J Nurs Adm. 2012;42(3):131-3. doi:10.1097/NNA.0b013e31824808b6. https://psnet.ahrq.gov/issue/leading-highly-visible-hospital-through-serious-repor…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39321/psn-pdf
    April 08, 2011 - Interns overestimate the effectiveness of their hand-off communication. April 8, 2011 Chang VY, Arora V, Lev-Ari S, et al. Interns overestimate the effectiveness of their hand-off communication. Pediatrics. 2010;125(3):491-496. doi:10.1542/peds.2009-0351. https://psnet.ahrq.gov/issue/interns-overestimate-effective…

  10. The Perils of Contrast Media | PSNet

    psnet.ahrq.gov/web-mm/perils-contrast-media
    March 01, 2007 - SPOTLIGHT CASE The Perils of Contrast Media Citation Text: Sadat U, Solomon R. The Perils of Contrast Media. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX En…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49639/psn-pdf
    November 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841139/psn-pdf
    December 14, 2022 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. December 14, 2022 Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. PSNet [internet]. 2022. https://psnet.ah…

  13. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
    September 01, 2014 - PowerPoint Presentation Spotlight A Lot of Pain (Medications) 1 This presentation is based on the September 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Shoshana J. Herzig, MD, MPH, Division of General Medicine, Beth Israel Deaconess Medic…

  14. Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx Spotlight Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49549/psn-pdf
    December 06, 2007 - Elopement December 1, 2007 Gerardi D. Elopement. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/elopement Case Objectives Define elopement and differentiate it from wandering and leaving against medical advice. Identify leading contributors to elopement events. Describe strategies for preventing elopement…

  16. Slow Down: Right Drug, Wrong Formulation | PSNet

    psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
    October 13, 2018 - Slow Down: Right Drug, Wrong Formulation Citation Text: Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndN…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49669/psn-pdf
    November 01, 2012 - Transfusion Overload November 1, 2012 Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfusion-overload Case Objectives Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit below 30% are not supported by the evidence.…

  18. Treatment Challenges After Discharge | PSNet

    psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
    January 03, 2017 - SPOTLIGHT CASE Treatment Challenges After Discharge Citation Text: Coffey C. Treatment Challenges After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar Bib…

  19. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
    January 01, 2024 - Spotlight Spotlight A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis 1 Source and Credits This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Garth Utter, MD, MSc, FACS…

  20. Statistical Brief #5

    hcup-us.ahrq.gov/reports/statbriefs/sb5.jsp
    May 01, 2006 - Statistical Brief #5 An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs Email Updates …
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