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psnet.ahrq.gov/issue/what-happened-patient-safety
August 23, 2007 - podcast (hosted by Institute for Healthcare Improvement leaders Don Berwick, MD and Kedar Mate, MD) features
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psnet.ahrq.gov/node/49503/psn-pdf
February 01, 2006 - In this case, the safety features of the ADM were bypassed on the nursing unit by the use of the portable … understandable) solution from their perspective, but it also represents a workaround that
bypasses the safety features … Placing medications from the ADM into another medication cart circumvents the intended safety
features
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psnet.ahrq.gov/glossary/handoffs-and-handovers
September 13, 2021 - assessing and managing a patient, upon completion of her work, provides a brief summary of the salient features
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - before leaving the room) may help to a limited extent, but they are much less reliable than safety features … Instead of each manufacturer determining the minimum acceptable safety design features for each of their … specialists to develop a prototype infusion pump and simulation test environment that investigates the design features
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psnet.ahrq.gov/issue/joshuas-story
February 26, 2014 - This video features an in-depth interview with the father of an infant who died following delayed diagnosis
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psnet.ahrq.gov/issue/special-section-human-factors-and-ergonomics-operating-room-contributions-advance-surgical
September 01, 2018 - This special issue features the work of multidisciplinary research teams that explored human factors
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psnet.ahrq.gov/issue/acr-recommendations-use-chest-radiography-and-computed-tomography-ct-suspected-covid-19
August 14, 2019 - shown that the sensitivity of chest CT is only 67-93% among patients with viral pneumonia and imaging features
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psnet.ahrq.gov/issue/aspects-healthcare-quality-are-important-health-professionals-and-patients-qualitative-study
September 08, 2021 - this qualitative study, researchers explore physician, nurse , and patient perspectives about what features
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psnet.ahrq.gov/issue/scoping-review-real-time-automated-clinical-deterioration-alerts-and-evidence-impacts
February 16, 2022 - patient outcomes, Authors suggest that workflow and integration of the early warning system model’s features
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psnet.ahrq.gov/node/34769/psn-pdf
March 28, 2005 - Vaughan refers to this second tendency
as the “normalization of deviance,” a phenomenon that shares many features
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psnet.ahrq.gov/issue/e-prescribing-efficiency-quality-lessons-computerization-uk-family-practice
October 01, 2014 - electronic health records is more prevalent in the United Kingdom than the United States and identify features
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psnet.ahrq.gov/issue/building-cultures-high-reliability-lessons-high-reliability-organization-paradigm
September 05, 2018 - This article provides a brief history of the concept of high reliability organizations (HROs) and key features
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psnet.ahrq.gov/issue/benefits-and-risks-using-smart-pumps-reduce-medication-error-rates-systematic-review
July 16, 2019 - discussed in a recent qualitative study , nurses frequently employ workarounds that may bypass some safety features
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psnet.ahrq.gov/issue/procuring-interoperability-achieving-high-quality-connected-and-person-centered-care
September 19, 2018 - The report advocates for adjusting purchasing behaviors to focus less on the price and features of each
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psnet.ahrq.gov/issue/challenger-launch-decision-risky-technology-culture-and-deviance-nasa
November 18, 2015 - refers to this second tendency as the “ normalization of deviance ,” a phenomenon that shares many features
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psnet.ahrq.gov/issue/quality-value-and-patient-safety-orthopedic-surgery
April 21, 2021 - intervals as marker of missed diagnostic opportunities in bladder and kidney cancer patients with alarm features
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - This case is demonstrative of cognitive errors associated with lack of knowledge of the features of, … While it can mimic meningitis, SEA should be considered in patients with risk factors and historical features … Blood cultures are commonly obtained from patients with SEA when they present with fever or other features … However, if the patient has features of sepsis or neurologic deficits, or if operative intervention will … Patients with neck or back pain without neurologic deficit or fever, but with risk factors or concerning features
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
August 01, 2014 - Surgery. 1982;92:765–770. http://www.ncbi.nlm.nih.gov/pubmed/7123497
10
History and Features
Hippocrates … Staging of necrotizing fasciitis based on the evolving cutaneous features. … //www.ncbi.nlm.nih.gov/pubmed/2031360
21
Strategies to Improve Diagnosis (2)
Three other cutaneous features
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psnet.ahrq.gov/issue/i-wish-i-had-seen-test-result-earlier-dissatisfaction-test-result-management-systems-primary
February 15, 2011 - their practice patterns in managing test results, their satisfaction with current systems, and what features
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psnet.ahrq.gov/issue/developing-implementing-evaluating-electronic-apparent-cause-analysis-across-health-care
February 07, 2018 - article describes the development of an electronic apparent cause analysis (eACA) tool, which combines features