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Showing results for "failures".

  1. The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related errors associated with two commercial systems in hospitals. | PSNet

    psnet.ahrq.gov/issue/safety-electronic-prescribing-manifestations-mechanisms-and-rates-system-related-errors
    February 15, 2012 - Study The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related errors associated with two commercial systems in hospitals. Citation Text: Westbrook JI, Baysari M, Li L, et al. The safety of electronic prescribing: manifestations, mechanisms, and rates…

  2. Ambulatory Care Compact to Organize Risk and Decisionmaking (ACCORD) | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/ambulatory-care-compact-organize-risk-and-decisionmaking-accord
    January 01, 2023 - Ambulatory Care Compact to Organize Risk and Decisionmaking (ACCORD) Project Final Report ( PDF , 857.15 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the…

  3. National Quality Strategy Priority: Effective Treatment | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part3-nqs5.html
    October 01, 2015 - Chartbook for Hispanic Health Care National Quality Strategy Priority: Effective Treatment Previous Page Next Page Table of Contents Chartbook for Hispanic Health Care Acknowledgments Health Care For Hispanics National Quality Strategy Priorities: Patient Safety National Quality Strategy Pri…

  4. A Future Vision for Better Diagnostic Outcomes | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load5.html
    May 01, 2024 - Cognitive Load Theory and Its Impact on Diagnostic Accuracy A Future Vision for Better Diagnostic Outcomes Previous Page Next Page Table of Contents Cognitive Load Theory and Its Impact on Diagnostic Accuracy Introduction to Diagnostic Errors Fundamental Concepts for Understanding Cognitive Load…

  5. Toth-Pal E et al. 2008 "Implementing a clinical decision-support system in practice: a qualitative analysis of influencing attitudes and characteristics among general practitioners." | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/toth-pal-e
    January 01, 2023 - Toth-Pal E et al. 2008 "Implementing a clinical decision-support system in practice: a qualitative analysis of influencing attitudes and characteristics among general practitioners." Reference Toth-Pal E, Wardh I, Strender L-E, et al. Implementing a clinical decision-support system in practice: a qual…

  6. A Community-Shared Clinical Abstract to Improve Care - Final Report | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/community-shared-clinical-abstract-improve-care/final-report
    January 01, 2023 - A Community-Shared Clinical Abstract to Improve Care - Final Report Citation Connelly D. A Community-Shared Clinical Abstract to Improve Care - Final Report. (Prepared by Fairview Health Services under Grant No. UC1 HS016155). Rockville, MD: Agency for Healthcare Research and Quality, 2010. PDF…

  7. Fairview Health Services | Digital Healthcare Research

    digital.ahrq.gov/organization/fairview-health-services
    January 01, 2023 - Fairview Health Services A Community-Shared Clinical Abstract to Improve Care - 2010 Principal Investigator Connelly, Donald Project Name A Community-Shared Clinical Abstract to Improve Care A Community-Shared Clinical Abstract to Improve …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41697/psn-pdf
    September 19, 2012 - From good to better: toward a patient safety initiative in dentistry. September 19, 2012 Ramoni R, Walji MF, White J, et al. From good to better: toward a patient safety initiative in dentistry. J Am Dent Assoc. 2012;143(9):956-60. https://psnet.ahrq.gov/issue/good-better-toward-patient-safety-initiative-dentistry…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39091/psn-pdf
    June 28, 2011 - Integration of prospective and retrospective methods for risk analysis in hospitals. June 28, 2011 Kessels-Habraken M, van der Schaaf TW, De Jonge J, et al. Integration of prospective and retrospective methods for risk analysis in hospitals. Int J Qual Health Care. 2009;21(6):427-32. doi:10.1093/intqhc/mzp043. ht…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46558/psn-pdf
    November 01, 2017 - Using fault trees to advance understanding of diagnostic errors. November 1, 2017 Rogith D, Iyengar S, Singh H. Using Fault Trees to Advance Understanding of Diagnostic Errors. Jt Comm J Qual Patient Saf. 2017;43(11):598-605. doi:10.1016/j.jcjq.2017.06.007. https://psnet.ahrq.gov/issue/using-fault-trees-advance-un…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837001/psn-pdf
    April 27, 2022 - Final Report of the Ockenden Review. April 27, 2022 London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294. https://psnet.ahrq.gov/issue/final-report-ockenden-review Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves as the final conclusions of an i…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844054/psn-pdf
    March 12, 2025 - Lewis Blackman Patient Safety Award. December 17, 2024 Chicago, IL: American College of Graduate Medical Education. https://psnet.ahrq.gov/issue/lewis-blackman-patient-safety-award Lewis Blackman was a young man who lost his life to medical error when the severity of his condition after elective surgery was unreco…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39440/psn-pdf
    September 19, 2016 - Toward understanding errors in inpatient psychiatry: a qualitative inquiry. September 19, 2016 Cullen SW, Nath SB, Marcus SC. Toward understanding errors in inpatient psychiatry: a qualitative inquiry. Psychiatr Q. 2010;81(3):197-205. doi:10.1007/s11126-010-9129-z. https://psnet.ahrq.gov/issue/toward-understanding…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41418/psn-pdf
    June 15, 2012 - Speaking across the drapes: communication strategies of anesthesiologists and obstetricians during a simulated maternal crisis. June 15, 2012 Minehart RD, Pian-Smith MCM, Walzer TB, et al. Speaking across the drapes: communication strategies of anesthesiologists and obstetricians during a simulated maternal crisis…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38892/psn-pdf
    August 26, 2009 - Wrong site surgery near misses and actual occurrences. August 26, 2009 Blanco M, Clarke JR, Martindell D. Wrong site surgery near misses and actual occurrences. AORN J. 2009;90(2):215-8, 221-2. doi:10.1016/j.aorn.2009.07.010. https://psnet.ahrq.gov/issue/wrong-site-surgery-near-misses-and-actual-occurrences This a…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43818/psn-pdf
    January 21, 2015 - A report on 15 years of clinical negligence claims in rhinology. January 21, 2015 Geyton T, Odutoye T, Mathew R. A report on 15 years of clinical negligence claims in rhinology. Am J Rhinol Allergy. 2014;28(6):219-23. doi:10.2500/ajra.2014.28.4118. https://psnet.ahrq.gov/issue/report-15-years-clinical-negligence-c…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43833/psn-pdf
    February 04, 2015 - Sterile compounding: clinical, legal, and regulatory implications for patient safety. February 4, 2015 Qureshi N, Wesolowicz L, Stievater T, et al. Sterile compounding: clinical, legal, and regulatory implications for patient safety. J Manag Care Spec Pharm. 2014;20(12):1183-1191. https://psnet.ahrq.gov/issue/ster…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849139/psn-pdf
    May 17, 2023 - How the opioid backlash went wrong. May 17, 2023 Freedman DH.  Newsweek Magazine. May 12, 2023. https://psnet.ahrq.gov/issue/how-opioid-backlash-went-wrong The unintended consequences of reductions in access to prescription opioids can result in poor addiction care and ineffective pain management. This articl…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44437/psn-pdf
    September 04, 2015 - A piece of my mind. Writing the wrong. September 4, 2015 Patel JJ. A PIECE OF MY MIND. Writing the Wrong. JAMA. 2015;314(7):671-2. doi:10.1001/jama.2015.5281. https://psnet.ahrq.gov/issue/piece-my-mind-writing-wrong Despite the potential for electronic health record (EHR) systems to improve access to patient data,…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44478/psn-pdf
    September 09, 2015 - Oral chemotherapy: not just an ordinary pill. September 9, 2015 ISMP Canada. SafeMedicineUse. August 19, 2015;6:1-2. https://psnet.ahrq.gov/issue/oral-chemotherapy-not-just-ordinary-pill Chemotherapy delivered by any method is a high-alert medication. This news article provides tips for both patients and practitio…
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