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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45391/psn-pdf
    August 10, 2016 - Where are my instruments? Hazards in delivery of surgical instruments. August 10, 2016 Guédon ACP, Wauben LSGL, van der Eijk AC, et al. Where are my instruments? Hazards in delivery of surgical instruments. Surg Endosc. 2016;30(7):2728-35. doi:10.1007/s00464-015-4537-7. https://psnet.ahrq.gov/issue/where-are-my-in…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47914/psn-pdf
    May 22, 2019 - Hospitals look to computers to predict patient emergencies before they happen. May 22, 2019 Ross C. STAT. May 13, 2019. https://psnet.ahrq.gov/issue/hospitals-look-computers-predict-patient-emergencies-they-happen Nuisance alarms, interruptions, and insufficient staff availability can hinder effective monitoring …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40992/psn-pdf
    December 15, 2011 - Should patients get direct access to their laboratory test results?: An answer with many questions. December 15, 2011 Giardina TD, Singh H. Should patients get direct access to their laboratory test results? An answer with many questions. JAMA. 2011;306(22):2502-2503. doi:10.1001/jama.2011.1797. https://psnet.ahrq…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34717/psn-pdf
    January 14, 2011 - When doctors make mistakes. January 14, 2011 Gawande A. New Yorker. February 1, 1999:40-43. https://psnet.ahrq.gov/issue/when-doctors-make-mistakes Gawande uses a harrowing personal example of a medical error to illustrate that medical mistakes are not a problem of bad physicians. He contends that virtually everyo…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46698/psn-pdf
    February 07, 2018 - Enhancing the quality and safety of the perioperative patient. February 7, 2018 Staender S, Smith A. Enhancing the quality and safety of the perioperative patient. Curr Opin Anaesthesiol. 2017;30(6):730-735. doi:10.1097/ACO.0000000000000517. https://psnet.ahrq.gov/issue/enhancing-quality-and-safety-perioperative-p…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43462/psn-pdf
    September 12, 2016 - Preventable mortality after common urological surgery: failing to rescue? September 12, 2016 Sammon JD, Pucheril D, Abdollah F, et al. Preventable mortality after common urological surgery: failing to rescue? BJU Int. 2015;115(4):666-674. doi:10.1111/bju.12833. https://psnet.ahrq.gov/issue/preventable-mortality-af…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865932/psn-pdf
    May 22, 2024 - Cognitive Load Theory and its Impact on Diagnostic Accuracy. May 22, 2024 Knees M, Raffel KE, Kissler M, et al. Rockville, MD: Agency for Healthcare Research and Quality; May 2024. Publication No. 24-0010-2-EF. https://psnet.ahrq.gov/issue/cognitive-load-theory-and-its-impact-diagnostic-accuracy Cognition plays a…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38640/psn-pdf
    January 18, 2012 - Nurses' responses to medication errors: suggestions for the development of organizational strategies to improve reporting. January 18, 2012 Covell CL, Ritchie JA. Nurses' responses to medication errors: suggestions for the development of organizational strategies to improve reporting. J Nurs Care Qual. 2009;24(4):…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39039/psn-pdf
    October 21, 2009 - Quality of medication use in primary care—mapping the problem, working to a solution: a systematic review of the literature. October 21, 2009 Garfield S, Barber N, Walley P, et al. Quality of medication use in primary care--mapping the problem, working to a solution: a systematic review of the literature. BMC Med.…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46659/psn-pdf
    December 06, 2017 - Focus On: Health Care Policy and Quality. December 6, 2017 AJR Am J Roentgenol. 2017;209(5):965-1008;w333-w334. https://psnet.ahrq.gov/issue/focus-health-care-policy-and-quality Radiologists play a critical role in safe diagnostic imaging and communication of test results. Articles in this special issue explore cl…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46333/psn-pdf
    June 25, 2018 - High reliability leadership: a conceptual framework. June 25, 2018 Martínez-Córcoles M. High reliability leadership: A conceptual framework. J Contingencies Crisis Manage. 2017;26(2):237-246. doi:10.1111/1468-5973.12187. https://psnet.ahrq.gov/issue/high-reliability-leadership-conceptual-framework Leadership engag…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836834/psn-pdf
    March 30, 2022 - Dying for Care. March 30, 2022 Stein L, Fraser J, Penzenstadler N et al. USA Today. March 10, 2022. https://psnet.ahrq.gov/issue/dying-care Nursing home residents, staff, and care processes were particularly vulnerable to COVID-19. This collection of resources examines data and documentation involving one nursing …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50449/psn-pdf
    October 09, 2019 - Systematic review of malpractice litigation in the diagnosis and treatment of acute stroke October 9, 2019 Haslett JJ, Genadry L, Zhang X, et al. Systematic Review of Malpractice Litigation in the Diagnosis and Treatment of Acute Stroke. Stroke. 2019;50(10):2858-2864. doi:10.1161/STROKEAHA.119.025352. https://psne…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45789/psn-pdf
    January 11, 2017 - Concurrent and Overlapping Surgeries: Additional Measures Warranted. January 11, 2017 US Senate Finance Committee. December 6, 2016. https://psnet.ahrq.gov/issue/concurrent-and-overlapping-surgeries-additional-measures-warranted The practice of scheduling concurrent surgeries has raised concerns about increased ri…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42984/psn-pdf
    February 26, 2014 - Delivering the truth: challenges and opportunities for error disclosure in obstetrics. February 26, 2014 Carranza L, Lyerly AD, Lipira L, et al. Delivering the Truth. Obstetrics & Gynecology. 2014;123(3). doi:10.1097/aog.0000000000000130. https://psnet.ahrq.gov/issue/delivering-truth-challenges-and-opportunities-e…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41822/psn-pdf
    November 07, 2012 - A case of adverse drug reaction induced by dispensing error. November 7, 2012 Gallelli L, Staltari O, Palleria C, et al. A case of adverse drug reaction induced by dispensing error. J Forensic Leg Med. 2012;19(8):497-8. doi:10.1016/j.jflm.2012.04.026. https://psnet.ahrq.gov/issue/case-adverse-drug-reaction-induced…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39393/psn-pdf
    March 24, 2010 - Lack of emergency medical services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care. March 24, 2010 Laudermilch DJ, Schiff MA, Nathens AB, et al. Lack of emergency medical services documentation is associated with poor patient outcomes: a validation …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42470/psn-pdf
    August 07, 2013 - Does inappropriate selectivity in information use relate to diagnostic errors and patient harm? The diagnosis of patients with dyspnea. August 7, 2013 Zwaan L, Thijs A, Wagner C, et al. Does inappropriate selectivity in information use relate to diagnostic errors and patient harm? The diagnosis of patients with dy…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836762/psn-pdf
    March 16, 2022 - Physician liability in the age of data reliance and errors. March 16, 2022 Montesantos L. Ann Health Law Life Sci. 2022;31(Spring):179-215. https://psnet.ahrq.gov/issue/physician-liability-age-data-reliance-and-errors Health information technologies (HIT) and advanced learning systems, if poorly designed, used, ma…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47954/psn-pdf
    August 07, 2019 - Special Issue on Resilience Engineering and High Reliability Organizations. August 7, 2019 Wears RL, Roberts KH, eds. Safety Sci. 2019;117;458-533. https://psnet.ahrq.gov/issue/special-issue-resilience-engineering-and-high-reliability-organizations Resilience is an organizational characteristic that enables indivi…
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