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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72608/psn-pdf
    December 23, 2020 - Incidence of Adverse Events in Indian Health Service Hospitals. December 23, 2020 Office of the Inspector General: Washington DC; December 2020. OIG report OEI-06-17-00530. https://psnet.ahrq.gov/issue/incidence-adverse-events-indian-health-service-hospitals Challenges beset safe care delivery for indigenous …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41534/psn-pdf
    July 25, 2012 - Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. July 25, 2012 Hu Y-Y, Arriaga AF, Roth EM, et al. Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. Ann Surg. 2012;256(2):203-10. doi:10.1097/SLA.0b013e…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46326/psn-pdf
    October 18, 2017 - Surgical Patient Safety: A Case-Based Approach. October 18, 2017 Stahel PF, ed. New York, NY: McGraw-Hill Education/Medical; 2017. ISBN: 9780071842631. https://psnet.ahrq.gov/issue/surgical-patient-safety-case-based-approach Surgical residency can be a stressful learning experience. This textbook provides an introd…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44074/psn-pdf
    November 16, 2015 - Investigating Clinical Incidents in the NHS. November 16, 2015 Sixth Report of Session 2014–15. House of Commons Public Administration Select Committee. London, England: The Stationery Office; March 27, 2015. Publication HC 886. https://psnet.ahrq.gov/issue/investigating-clinical-incidents-nhs Applying evidence ge…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46963/psn-pdf
    April 18, 2018 - A Just Culture Guide. April 18, 2018 NHS Improvement. London, UK: National Health Service; March 15, 2018. https://psnet.ahrq.gov/issue/just-culture-guide Although focusing on system failure has been highlighted as key to improving patient safety, individual behaviors must also be recognized as contributors to ris…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38783/psn-pdf
    September 02, 2009 - Medical negligence in drug associated deaths. September 2, 2009 Madea B, Musshoff F, Preuss J. Medical negligence in drug associated deaths. Forensic Sci Int. 2009;190(1-3):67-73. doi:10.1016/j.forsciint.2009.05.014. https://psnet.ahrq.gov/issue/medical-negligence-drug-associated-deaths This study reports that acc…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46461/psn-pdf
    November 01, 2017 - Complications: acknowledging, managing, and coping with human error. November 1, 2017 Helo S, Moulton C-AE. Complications: acknowledging, managing, and coping with human error. Transl Androl Urol. 2017;6(4):773-782. doi:10.21037/tau.2017.06.28. https://psnet.ahrq.gov/issue/complications-acknowledging-managing-and-…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43910/psn-pdf
    November 23, 2016 - Error disclosure and family members' reactions: does the type of error really matter? November 23, 2016 Leone D, Lamiani G, Vegni E, et al. Error disclosure and family members' reactions: does the type of error really matter? Patient Educ Couns. 2015;98(4):446-52. doi:10.1016/j.pec.2014.12.011. https://psnet.ahrq.…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34100/psn-pdf
    February 09, 2011 - Safety of patients isolated for infection control. February 9, 2011 Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA. 2003;290(14):1899-1905. https://psnet.ahrq.gov/issue/safety-patients-isolated-infection-control This study discovered that patients isolated for coloniza…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47218/psn-pdf
    January 09, 2019 - The accuracy of medical dispatch—a systematic review. January 9, 2019 Bohm K, Kurland L. The accuracy of medical dispatch - a systematic review. Scand J Trauma Resusc Emerg Med. 2018;26(1):94. doi:10.1186/s13049-018-0528-8. https://psnet.ahrq.gov/issue/accuracy-medical-dispatch-systematic-review Medical dispatch i…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38976/psn-pdf
    October 07, 2009 - Radiology errors: are we learning from our mistakes? October 7, 2009 Mankad K, Hoey ETD, Jones JB, et al. Radiology errors: are we learning from our mistakes? Clin Radiol. 2009;64(10):988-93. doi:10.1016/j.crad.2009.06.002. https://psnet.ahrq.gov/issue/radiology-errors-are-we-learning-our-mistakes This survey stud…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44093/psn-pdf
    April 29, 2015 - South Carolina medication error bill is dangerously off target. April 29, 2015 ISMP Medication Safety Alert! Acute Care Edition. April 9, 2015;20:1,4. https://psnet.ahrq.gov/issue/south-carolina-medication-error-bill-dangerously-target This newsletter article reports on issues related to a legislation, drafted in …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46085/psn-pdf
    July 12, 2017 - Pediatric radiology malpractice claims—characteristics and comparison to adult radiology claims. July 12, 2017 Breen MA, Dwyer K, Yu-Moe W, et al. Pediatric radiology malpractice claims - characteristics and comparison to adult radiology claims. Pediatr Radiol. 2017;47(7):808-816. doi:10.1007/s00247-017-3873-2. ht…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43977/psn-pdf
    November 16, 2015 - Patient perspectives on test result communication in primary care: a qualitative study. November 16, 2015 Litchfield I, Bentham L, Lilford RJ, et al. Patient perspectives on test result communication in primary care: a qualitative study. Br J Med Pract. 2015;65(632):e133-e140. doi:10.3399/bjgp15X683929. https://ps…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848827/psn-pdf
    May 10, 2023 - TQIP Mortality Reporting System Case Reports. May 10, 2023 ACS TQIP Mortality Reporting System Writing Group. J Trauma Acute Care Surg. 2023. https://psnet.ahrq.gov/issue/tqip-mortality-reporting-system-case-reports Anonymous case reporting provides opportunities to examine unexpected patient harm instances to pin…

  16. Rural Hospital Collaborative for Excellence Using IT - Final Report | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/rural-hospital-collaborative-excellence-using-it/final-report
    January 01, 2023 - Rural Hospital Collaborative for Excellence Using IT - Final Report Citation Brooks H. Rural Hospital Collaborative for Excellence Using IT - Final Report. (Prepared by Palo Pinto General Hospital under Grant No. UC1 HS015431). Rockville, MD: Agency for Healthcare Research and Quality, 2007. PDF…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836761/psn-pdf
    March 16, 2022 - Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. March 16, 2022 Padula WV, Armstrong DG, Goldman DP. Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. Mayo Clin Proc. 2022;97(2):221-224. doi:10.1016/j.mayocp.2021.1…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60607/psn-pdf
    June 17, 2020 - When health care moves online, many patients are left behind. June 17, 2020 Renault M. When health care moves online, many patients are left behind. Wired Online. 2020;(June 8, 2020). https://psnet.ahrq.gov/issue/when-health-care-moves-online-many-patients-are-left-behind The emergence of telemedicine as a primar…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836727/psn-pdf
    March 09, 2022 - A family and hospital's journey and commitment to improving diagnostic safety. March 9, 2022 Wyner D, Wyner F, Brumbaugh D, et al. A family and hospital's journey and commitment to improving diagnostic safety. Pediatrics. 2021;148(6):e2021053091. doi:10.1542/peds.2021-053091. https://psnet.ahrq.gov/issue/family-an…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842779/psn-pdf
    January 12, 2011 - Resilience Engineering in Practice: a Guidebook. January 12, 2011 Hollnagel E, Parie?s J, Woods DD et al eds. Farnham UK; Ashgate, 2011. ISBN: 9781472420749 https://psnet.ahrq.gov/issue/resilience-engineering-practice-guidebook Safety-critical industries rely on organizational aptitude to respond to disr…
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