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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847056/psn-pdf
    April 05, 2023 - Early diagnosis of cancer: systems approach to support clinicians in primary care. April 5, 2023 Black GB, Lyratzopoulos G, Vincent CA, et al. Early diagnosis of cancer: systems approach to support clinicians in primary care. BMJ. 2023;380:e071225. doi:10.1136/bmj-2022-071225. https://psnet.ahrq.gov/issue/early-di…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863210/psn-pdf
    February 28, 2024 - Disparities in racial, ethnic, and payer groups for pediatric safety events in US hospitals. February 28, 2024 Parikh K, Hall M, Tieder JS, et al. Disparities in racial, ethnic, and payer groups for pediatric safety events in US hospitals. Pediatrics. 2024;153(3):e2023063714. doi:10.1542/peds.2023-063714. https://…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847553/psn-pdf
    April 12, 2023 - Listening, Learning, Responding to Concerns. April 12, 2023 Newcastle Upon Tyne, UK: Care Quality Commission; March 2023. https://psnet.ahrq.gov/issue/listening-learning-responding-concerns The ability to raise patient safety concerns without fear of retribution is a core element of a safety culture. This pair of …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847548/psn-pdf
    April 12, 2023 - Minnesota lets nurses practice while disciplinary investigations drag on. Patients keep getting hurt. April 12, 2023 Hopkins E, Kohler J. ProPublica. April 3, 2023. https://psnet.ahrq.gov/issue/minnesota-lets-nurses-practice-while-disciplinary-investigations-drag-patients- keep-getting Systemic bureaucracy can co…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844059/psn-pdf
    February 08, 2023 - Misdiagnosis in the emergency department: time for a system solution. February 8, 2023 Edlow JA, Pronovost PJ. Misdiagnosis in the emergency department: time for a system solution. JAMA. 2023;329(8):631-632. doi:10.1001/jama.2023.0577. https://psnet.ahrq.gov/issue/misdiagnosis-emergency-department-time-system-solu…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47825/psn-pdf
    March 06, 2019 - Diagnostic error as a result of drug-laboratory test interactions. March 6, 2019 van Balveren JA, van de Venne WPHGV-, Erdem-Eraslan L, et al. Diagnostic error as a result of drug- laboratory test interactions. Diagnosis (Berl). 2019;6(1):69-71. doi:10.1515/dx-2018-0098. https://psnet.ahrq.gov/issue/diagnostic-err…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38123/psn-pdf
    June 10, 2010 - Patient safety incidents associated with equipment in critical care: a review of reports to the UK National Patient Safety Agency. June 10, 2010 Thomas AN, Galvin I. Patient safety incidents associated with equipment in critical care: a review of reports to the UK National Patient Safety Agency. Anaesthesia. 2008;…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39823/psn-pdf
    April 04, 2011 - Cognitive error as the most frequent contributory factor in cases of medical injury: a study on verdict's judgment among closed claims in Japan. April 4, 2011 Tokuda Y, Kishida N, Konishi R, et al. Cognitive error as the most frequent contributory factor in cases of medical injury: a study on verdict's judgment am…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46050/psn-pdf
    August 03, 2017 - Video analysis of factors associated with response time to physiologic monitor alarms in a children's hospital. August 3, 2017 Bonafide CP, Localio R, Holmes JH, et al. Video Analysis of Factors Associated With Response Time to Physiologic Monitor Alarms in a Children's Hospital. JAMA Pediatr. 2017;171(6):524-531. …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41959/psn-pdf
    January 16, 2013 - Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report. January 16, 2013 Lago P, Bizzarri G, Scalzotto F, et al. Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improv…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841481/psn-pdf
    January 01, 2023 - Trainees' perceptions of being allowed to fail in clinical training: a sense-making model. December 14, 2022 Klasen JM, Teunissen PW, Driessen E, et al. Trainees' perceptions of being allowed to fail in clinical training: a sense?making model. Med Educ. 2023;57(5):430-439. doi:10.1111/medu.14966. https://psnet.ahr…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50744/psn-pdf
    December 18, 2019 - EMS crews brought patients to the hospital with misplaced breathing tubes. None of them survived December 18, 2019 Arditi L. Peoples Public Radio. December 3, 2019. https://psnet.ahrq.gov/issue/ems-crews-brought-patients-hospital-misplaced-breathing-tubes-none-them- survived Emergency medical services are often p…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39443/psn-pdf
    March 23, 2011 - Real-time clinical alerting: effect of an automated paging system on response time to critical laboratory values—a randomised controlled trial. March 23, 2011 Etchells E, Adhikari NKJ, Cheung C, et al. Real-time clinical alerting: effect of an automated paging system on response time to critical laboratory values-…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35312/psn-pdf
    January 02, 2017 - Medication errors involving wrong administration technique. January 2, 2017 Santell JP, Cousins DD. Medication Errors Involving Wrong Administration Technique. The Joint Commission Journal on Quality and Patient Safety. 2016;31(9). doi:10.1016/s1553-7250(05)31068-3. https://psnet.ahrq.gov/issue/medication-errors-i…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861294/psn-pdf
    January 24, 2024 - Shining a glaring light on surgery: technology that records every move aims to improve safety. January 24, 2024 Freyer FJ. Boston Globe. January 13, 2024. https://psnet.ahrq.gov/issue/shining-glaring-light-surgery-technology-records-every-move-aims-improve- safety The surgical black box uses cameras and microphon…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45588/psn-pdf
    January 23, 2017 - Computer-assisted process modeling to enhance intraoperative safety in cardiac surgery. January 23, 2017 Tarola CL, Quin JA, Haime ME, et al. Computer-Assisted Process Modeling to Enhance Intraoperative Safety in Cardiac Surgery. JAMA Surg. 2016;151(12):1183-1186. doi:10.1001/jamasurg.2016.2839. https://psnet.ahrq…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38534/psn-pdf
    January 31, 2013 - Health care information technology vendors' "hold harmless" clause: implications for patients and clinicians. January 31, 2013 Koppel R, Kreda D. Health care information technology vendors' "hold harmless" clause: implications for patients and clinicians. JAMA. 2009;301(12):1276-8. doi:10.1001/jama.2009.398. https…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46865/psn-pdf
    March 07, 2018 - Chasing the 6-sigma: drawing lessons from the cockpit culture. March 7, 2018 Hickey EJ, Halvorsen F, Laussen PC, et al. Chasing the 6-sigma: Drawing lessons from the cockpit culture. J Thorac Cardiovasc Surg. 2017;155(2). doi:10.1016/j.jtcvs.2017.09.097. https://psnet.ahrq.gov/issue/chasing-6-sigma-drawing-lessons…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73522/psn-pdf
    July 21, 2021 - Federal speech rulings may embolden health care workers to call out safety issues. July 21, 2021 Meyer H. Kaiser Health News. July 9, 2021. https://psnet.ahrq.gov/issue/federal-speech-rulings-may-embolden-health-care-workers-call-out-safety- issues Whistleblower protections are a key component to raising awarenes…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843082/psn-pdf
    January 25, 2023 - Determination of unnecessary blood transfusion by comprehensive 15-hospital record review. January 25, 2023 Jadwin DF, Fenderson PG, Friedman MT, et al. Determination of unnecessary blood transfusion by comprehensive 15-hospital record review. Jt Comm J Qual Patient Saf. 2023;49(1):42-52. doi:10.1016/j.jcjq.2022.1…
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