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Showing results for "failures".

5281. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865346/psn-pdf
      March 27, 2024 - RaDonda Vaught says some system practices contributed to fatal mistake. March 27, 2024 Clark C. MedPage Today. March 14, 2024. https://psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake Stories from clinicians involved in errors provide unique insights into both the human an…

5282. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50561/psn-pdf
      October 16, 2019 - Patient Safety Organizations: Hospital Participation, Value, and Challenges. October 16, 2019 US Department of Health and Human Services; Office of the Inspector General, September 2019. OIG Report No. OEI-01-17-00420.  https://psnet.ahrq.gov/issue/patient-safety-organizations-hospital-participation-value-and…

5283. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50870/psn-pdf
      February 05, 2020 - A survey of outpatient internal medicine clinician perceptions of diagnostic error. February 5, 2020 Matulis JC, Kok SN, Dankbar EC, et al. A survey of outpatient Internal Medicine clinician perceptions of diagnostic error. Diagnosis. 2020;7(2):107-114. doi:10.1515/dx-2019-0070. https://psnet.ahrq.gov/issue/survey…

5284. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/855003/psn-pdf
      November 01, 2023 - The hospital ran out of her child's cancer drug. Now she's fighting to end shortages. November 1, 2023 Noguchi Y. Health Shots and All Things Considered. National Public Radio. October 23, 2023. https://psnet.ahrq.gov/issue/hospital-ran-out-her-childs-cancer-drug-now-shes-fighting-end-shortages Drug shortages…

5285. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73911/psn-pdf
      October 06, 2021 - Misdiagnosis of acute myocardial infarction: a systematic review of the literature. October 6, 2021 Kwok CS, Bennett S, Azam Z, et al. Misdiagnosis of acute myocardial infarction: a systematic review of the literature. Crit Pathw Cardiol. 2021;20(3):155-162. doi:10.1097/hpc.0000000000000256. https://psnet.ahrq.gov…

5286. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50925/psn-pdf
      February 19, 2020 - Report of the Independent Inquiry into the Issues Raised by Paterson. February 19, 2020 James G. House Commons Report 31. Department of Health and Social Care. London, England: Crown Copyright; 2020. ISBN 9781528617284. https://psnet.ahrq.gov/issue/report-independent-inquiry-issues-raised-paterson Shari…

5287. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74067/psn-pdf
      November 10, 2021 - Conflict resolution: applying aviation crew resource management in healthcare. November 10, 2021 Braverman A. Conflict resolution: applying aviation crew resource management in healthcare. Nurs Manage. 2021;52(9):30-34. doi:10.1097/01.numa.0000771740.79361.1c. https://psnet.ahrq.gov/issue/conflict-resolution-apply…

5288. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38350/psn-pdf
      March 01, 2011 - A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety. March 1, 2011 Rodriguez-Paz JM, Mark L, Herzer KR, et al. A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards…

5289. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74044/psn-pdf
      November 03, 2021 - Challenges with requiring five characters during ADC drug searches via override. November 3, 2021 ISMP Medication Safety Alert! Acute care edition. October 21, 2021;26(21):1-3. https://psnet.ahrq.gov/issue/challenges-requiring-five-characters-during-adc-drug-searches-override Shortcuts in automated data entry beha…

5290. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36086/psn-pdf
      June 14, 2011 - Sensemaking of patient safety risks and hazards. June 14, 2011 Battles J, Dixon NM, Borotkanics RJ, et al. Sensemaking of patient safety risks and hazards. Health Serv Res. 2006;41(4 Pt 2):1555-1575. https://psnet.ahrq.gov/issue/sensemaking-patient-safety-risks-and-hazards This commentary discusses the concept of …

5291. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36463/psn-pdf
      July 10, 2008 - Missed opportunities in the primary care management of early acute ischemic heart disease. July 10, 2008 Sequist TD, Marshall R, Lampert S, et al. Missed opportunities in the primary care management of early acute ischemic heart disease. Arch Intern Med. 2006;166(20):2237-43. https://psnet.ahrq.gov/issue/missed-op…

5292. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46936/psn-pdf
      April 11, 2018 - You've detailed your last wishes, but doctors may not see them. April 11, 2018 Lamas D. https://psnet.ahrq.gov/issue/youve-detailed-your-last-wishes-doctors-may-not-see-them Advance care planning can affect patient safety if the information is unheeded, unavailable, or unread. Reporting on a physician's experienc…

5293. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45146/psn-pdf
      July 18, 2016 - Driving surgical quality using operative video. July 18, 2016 O'Mahoney PRA, Yeo HL, Lange MM, et al. Driving Surgical Quality Using Operative Video. Surg Innov. 2016;23(4):337-40. doi:10.1177/1553350616643616. https://psnet.ahrq.gov/issue/driving-surgical-quality-using-operative-video Although using video documen…

5294. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44764/psn-pdf
      February 10, 2016 - Human factors—recognising and minimising errors in our day to day practice. February 10, 2016 Green B, Tsiroyannis C, Brennan PA. Human factors--recognising and minimising errors in our day to day practice. Oral Dis. 2016;22(1):19-22. doi:10.1111/odi.12384. https://psnet.ahrq.gov/issue/human-factors-recognising-an…

5295. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43333/psn-pdf
      January 15, 2017 - A multidisciplinary, multifaceted improvement initiative to eliminate mislabelled laboratory specimens at a large tertiary care hospital. January 15, 2017 Seferian EG, Jamal S, Clark K, et al. A multidisciplinary, multifaceted improvement initiative to eliminate mislabelled laboratory specimens at a large tertiary…

5296. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42920/psn-pdf
      February 05, 2014 - How well do we communicate? A comparison of intraoperative diagnoses listed in pathology reports and operative notes. February 5, 2014 Talmon G, Horn A, Wedel W, et al. How well do we communicate?: a comparison of intraoperative diagnoses listed in pathology reports and operative notes. Am J Clin Pathol. 2013;140(…

5297. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43997/psn-pdf
      August 02, 2015 - Sentinel events, serious reportable events, and root cause analysis. August 2, 2015 Chen TC, Schein OD, Miller JW. Sentinel events, serious reportable events, and root cause analysis. JAMA Ophthalmol. 2015;133(6):631-632. doi:10.1001/jamaophthalmol.2015.0672. https://psnet.ahrq.gov/issue/sentinel-events-serious-re…

5298. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44724/psn-pdf
      November 25, 2015 - What's in your kit? A safety checkup may be in order. November 25, 2015 Paparella S. What's In Your Kit? A Safety Checkup May Be In Order. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association. 2015;41(6):513-5. doi:10.1016/j.jen.2015.07.001. https://psnet.ahrq.gov…

5299. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46137/psn-pdf
      August 03, 2017 - Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis. August 3, 2017 Schulz CM, Burden A, Posner KL, et al. Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage: A Closed Claims Analysis. Anesthesiology. 2017;127(2)…

5300. e-Coaching: Interactive Voice Response-Enhanced Care Transition Support for Complex Patients - Final Report | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/e-coaching-interactive-voice-response-enhanced-care-transition-support-complex/final-report
      January 01, 2023 - e-Coaching: Interactive Voice Response-Enhanced Care Transition Support for Complex Patients - Final Report Citation Ritchie C. e-Coaching: Interactive Voice Response-Enhanced Care Transition Support for Complex Patients - Final Report. (Prepared by the University of Alabama at Birmingham under Grant …