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Showing results for "failures".

7161. Shifting the learning curve. | PSNet
      psnet.ahrq.gov/issue/shifting-learning-curve
      March 09, 2009 - Commentary Shifting the learning curve. Citation Text: Reynolds T, Kong M-L. Shifting the learning curve. BMJ. 2010;341:c6260. doi:10.1136/bmj.c6260. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

7162. Nursing perception of the impact of automated dispensing cabinets on patient safety and ergonomics in a teaching health care center. | PSNet
      psnet.ahrq.gov/issue/nursing-perception-impact-automated-dispensing-cabinets-patient-safety-and-ergonomics
      September 27, 2016 - Study Nursing perception of the impact of automated dispensing cabinets on patient safety and ergonomics in a teaching health care center. Citation Text: Rochais E, Atkinson S, Guilbeault M, et al. Nursing perception of the impact of automated dispensing cabinets on patient safety and er…

7163. Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes. | PSNet
      psnet.ahrq.gov/issue/using-ora-explore-relationship-nursing-unit-communication-patient-safety-and-quality-outcomes
      December 11, 2008 - Study Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes. Citation Text: Effken JA, Carley KM, Gephart SM, et al. Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes. Int J Me…

7164. Foreword | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/tools/confid-report/foreword.html
      February 01, 2016 - Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance Foreword Previous Page Next Page Table of Contents Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance Foreword Introduction Part One: Physician Feedback Report Fundamentals …

7165. Systematic error and cognitive bias in obstetric ultrasound. | PSNet
      psnet.ahrq.gov/issue/systematic-error-and-cognitive-bias-obstetric-ultrasound
      December 13, 2023 - Commentary Systematic error and cognitive bias in obstetric ultrasound. Citation Text: Sotiriadis A, Odibo AO. Systematic error and cognitive bias in obstetric ultrasound. Ultrasound Obstet Gynecol. 2019;53(4):431-435. doi:10.1002/uog.20232. Copy Citation Format: DOI Google…

7166. Electronic medical record availability and primary care depression treatment. | PSNet
      psnet.ahrq.gov/issue/electronic-medical-record-availability-and-primary-care-depression-treatment
      November 16, 2022 - Study Electronic medical record availability and primary care depression treatment. Citation Text: Harman JS, Rost KM, Harle CA, et al. Electronic medical record availability and primary care depression treatment. J Gen Intern Med. 2012;27(8):962-7. doi:10.1007/s11606-012-2001-0. Copy …

7167. Health Care Quality and Disparities: Lessons from the First National Reports. | PSNet
      psnet.ahrq.gov/issue/health-care-quality-and-disparities-lessons-first-national-reports
      April 03, 2005 - Special or Theme Issue Health Care Quality and Disparities: Lessons from the First National Reports. Citation Text: Health Care Quality and Disparities: Lessons from the First National Reports. Kelley E, Moy E, Dayton E, et al. Med Care. 2005:43(3):I1-I88. Copy Citation …

7168. Interruptions and medication administration in critical care. | PSNet
      psnet.ahrq.gov/issue/interruptions-and-medication-administration-critical-care
      December 08, 2021 - Review Interruptions and medication administration in critical care. Citation Text: Bower R, Jackson C, Manning JC. Interruptions and medication administration in critical care. Nurs Crit Care. 2015;20(4):183-95. doi:10.1111/nicc.12185. Copy Citation Format: DOI Google Scho…

7169. Patient safety: it's not just carefulness, it's a culture. | PSNet
      psnet.ahrq.gov/issue/patient-safety-its-not-just-carefulness-its-culture
      December 24, 2008 - Commentary Patient safety: it's not just carefulness, it's a culture. Citation Text: Powell S. Patient Safety: it's not just carefulness, it's a culture. Lippincotts Case Manag. 2004;9(5):211-212. doi:10.1097/00129234-200409000-00001. Copy Citation Format: DOI Google Scho…

7170. The role of technology in clinician-to-clinician communication. | PSNet
      psnet.ahrq.gov/issue/role-technology-clinician-clinician-communication
      September 09, 2015 - Commentary The role of technology in clinician-to-clinician communication. Citation Text: McElroy LM, Ladner DP, Holl JL. The role of technology in clinician-to-clinician communication. BMJ Qual Saf. 2013;22(12):981-3. doi:10.1136/bmjqs-2013-002191. Copy Citation Format: …

7171. Using fault trees to advance understanding of diagnostic errors. | PSNet
      psnet.ahrq.gov/issue/using-fault-trees-advance-understanding-diagnostic-errors
      November 11, 2020 - Commentary Using fault trees to advance understanding of diagnostic errors. Citation Text: 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. Copy Citation F…

7172. Adverse events in medicine: easy to count, complicated to understand, and complex to prevent. | PSNet
      psnet.ahrq.gov/issue/adverse-events-medicine-easy-count-complicated-understand-and-complex-prevent
      July 15, 2009 - Commentary Adverse events in medicine: easy to count, complicated to understand, and complex to prevent. Citation Text: Amalberti R, Benhamou D, Auroy Y, et al. Adverse events in medicine: easy to count, complicated to understand, and complex to prevent. J Biomed Inform. 2011;44(3):390…

7173. Adverse drug events in the elderly. | PSNet
      psnet.ahrq.gov/issue/adverse-drug-events-elderly
      April 21, 2011 - Review Adverse drug events in the elderly. Citation Text: Cresswell KM, Fernando B, McKinstry B, et al. Adverse drug events in the elderly. Br Med Bull. 2007;83(1). doi:10.1093/bmb/ldm016. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…

7174. Adverse event protocol for interventional pain medicine: the importance of an organized response. | PSNet
      psnet.ahrq.gov/issue/adverse-event-protocol-interventional-pain-medicine-importance-organized-response
      January 12, 2022 - Study Adverse event protocol for interventional pain medicine: the importance of an organized response. Citation Text: Sitzman BT. Adverse Event Protocol for Interventional Pain Medicine: The Importance of an Organized Response. Pain Medicine. 2008;9(suppl 1). doi:10.1111/j.1526-4637.2…

7175. Tool: Perioperative Staff Safety Assessment (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/perioperative_asst.docx
      December 01, 2017 - Tool: Perioperative Staff Safety Assessment AHRQ Safety Program for Surgery Perioperative Staff Safety Assessment Introduction Problem Statement One of the strongest determinants of safety culture is whether local and hospital leadership respond to staff patient safety concerns. Frontline providers understand patie…

7176. System weaknesses as contributing causes of accidents in health care. | PSNet
      psnet.ahrq.gov/issue/system-weaknesses-contributing-causes-accidents-health-care
      August 31, 2022 - Study System weaknesses as contributing causes of accidents in health care. Citation Text: Ternov S, Akselsson R. System weaknesses as contributing causes of accidents in health care. Int J Qual Health Care. 2005;17(1):5-13. Copy Citation Format: Google Scholar PubMed Bib…

7177. Facilitating and impeding factors for physicians' error disclosure: a structured literature review. | PSNet
      psnet.ahrq.gov/issue/facilitating-and-impeding-factors-physicians-error-disclosure-structured-literature-review
      September 12, 2011 - Review Facilitating and impeding factors for physicians' error disclosure: a structured literature review. Citation Text: Kaldjian LC, Jones EW, Rosenthal GE. Facilitating and impeding factors for physicians' error disclosure: a structured literature review. Jt Comm J Qual Patient Saf. 2…

7178. Reducing preventable medication safety events by recognizing renal risk. | PSNet
      psnet.ahrq.gov/issue/reducing-preventable-medication-safety-events-recognizing-renal-risk
      June 27, 2011 - Study Reducing preventable medication safety events by recognizing renal risk. Citation Text: Fields W, Tedeschi C, Foltz J, et al. Reducing preventable medication safety events by recognizing renal risk. Clin Nurse Spec. 2008;22(2):73-8; quiz 79-80. doi:10.1097/01.NUR.0000311795.69476…

7179. Maintaining safety in the dialysis facility. | PSNet
      psnet.ahrq.gov/issue/maintaining-safety-dialysis-facility
      May 25, 2011 - Commentary Maintaining safety in the dialysis facility. Citation Text: Kliger AS. Maintaining safety in the dialysis facility. Clin J Am Soc Nephrol. 2015;10(4):688-95. doi:10.2215/CJN.08960914. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7…

7180. Patient safety in home hemodialysis: quality assurance and serious adverse events in the home setting. | PSNet
      psnet.ahrq.gov/issue/patient-safety-home-hemodialysis-quality-assurance-and-serious-adverse-events-home-setting
      January 23, 2017 - Commentary Patient safety in home hemodialysis: quality assurance and serious adverse events in the home setting. Citation Text: Pauly RP, Eastwood DO, Marshall MR. Patient safety in home hemodialysis: quality assurance and serious adverse events in the home setting. Hemodial Int. 2015;1…