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Showing results for "finally".

41. Organizational culture as a source of high reliability. | PSNet
    psnet.ahrq.gov/issue/organizational-culture-source-high-reliability
    December 03, 2018 - Finally, the author describes the importance of storytelling in organizations, which allows people to

42. To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. | PSNet
    psnet.ahrq.gov/issue/tell-truth-ethical-and-practical-issues-disclosing-medical-mistakes-patients
    April 19, 2011 - Finally, practical issues in the disclosure of mistakes are outlined, including the challenges of when

43. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33800/psn-pdf
    January 01, 2015 - Finally, evidence from a multicenter outpatient study did not find a change in the rate of preventable … Finally, the authors noted the failure to systematically identify, track, and learn from CPOE errors

44. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73650/psn-pdf
    August 25, 2021 - population, it is not unusual for women to be misdiagnosed for many years as having asthma prior to finally … rate of recurrence, a pneumothorax in a patient with LAM needs to be managed with pleurodesis, as finally … Finally, clinicians should understand the principles of diagnostic uncertainty as they apply to patients

45. Is the "Surgical Personality" a Threat to Patient Safety? | PSNet
    psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
    February 24, 2021 - Once pericardiocentesis was finally performed, the child immediately improved and more than 200 cc of … Finally, the lessons of experience are communicated through a dense oral culture—inexperienced workers … Finally, there needs to be intolerance from organizational leaders of the behaviors that characterizes

46. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49863/psn-pdf
    May 01, 2019 - Finally, through her use of the CUS expression and clear articulation of her concerns, she obtained … Finally, a systems-based approach to prevent the adverse event in this case would focus on the technology … Finally, they can adopt effective practices such as using preoperative checklists to help identify potential

47. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49499/psn-pdf
    December 02, 2020 - seven different physicians evaluated a patient over the course of a month before the last provider finally … Finally, clinics should consider developing measurements of resident performance in clinic.

48. Unexpected hypoglycemia in a critically ill patient. | PSNet
    psnet.ahrq.gov/issue/unexpected-hypoglycemia-critically-ill-patient
    July 25, 2018 - Finally, a comment about the institution's response to the event is presented to illustrate the importance

49. Physician engagement in malpractice risk reduction: a UPHS case study. | PSNet
    psnet.ahrq.gov/issue/physician-engagement-malpractice-risk-reduction-uphs-case-study
    June 02, 2019 - August 3, 2022 Defensive medicine: it is time to finally slow down an epidemic.

50. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867845/psn-pdf
    February 26, 2025 - tabulated counts of patient safety reports that fell into each step to quantify where most issues arose.2 Finally … proactive risk assessments were analyzed together, there were a total of 32 unique failure modes.2 Finally

51. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49719/psn-pdf
    September 01, 2014 - for preventable incidents (8), and combined with other human error may result in patient harm.(9) Finally … Finally, if there was no simple indication by the patient monitor that the NIBP cuff wasn't cycled for … Finally, a decision support alert from the electronic anesthesia record would likely have prevented

52. Amphotericin Toxicity | PSNet
    psnet.ahrq.gov/web-mm/amphotericin-toxicity
    April 01, 2014 - Finally, the nurse administering the infusion (given during shift change) did not recognize that the … Finally, nursing could have caught the error prior to administration if smart pumps with dose-related … , dose, and duration have demonstrated a significant reduction in inappropriate prescribing.( 7 ) Finally

53. It's All in the Syringe | PSNet
    psnet.ahrq.gov/web-mm/its-all-syringe
    February 01, 2013 - Finally, we may offer urgent treatments with triptans for acute migraine, albuterol for asthma, epinephrine … Dispensing then requires multiple checks before the drugs are finally delivered to the unit. … Finally, the practice probably lacked policies for the use of high-hazard drugs such as insulin, such

54. Strengthening the core. Middle managers play a vital role in improving safety. | PSNet
    psnet.ahrq.gov/issue/strengthening-core-middle-managers-play-vital-role-improving-safety
    April 25, 2016 - May 18, 2012 Are we finally getting serious about medical errors?

55. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49522/psn-pdf
    November 01, 2006 - Finally, direct harm can occur when caregivers are faced with diagnostic or therapeutic uncertainty, … Finally, patients and payers may misinterpret quality performance information and make poor choices … Finally, where appropriate, payers should consider incorporating predictable unintended events into … Finally, regulatory agencies must be willing to modify problematic measures.

56. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | PSNet
    psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
    October 01, 2004 - Finally, direct harm can occur when caregivers are faced with diagnostic or therapeutic uncertainty, … Finally, patients and payers may misinterpret quality performance information and make poor choices about … Finally, where appropriate, payers should consider incorporating predictable unintended events into the … Finally, regulatory agencies must be willing to modify problematic measures.

57. Production Pressures | PSNet
    psnet.ahrq.gov/web-mm/production-pressures
    November 16, 2022 - cover unexpected absences and rarely cancelled a case, scrambled to try to cover the ECT procedure, finally … But finally, to avoid delays in the ECT administration, he reluctantly agreed to come to the day surgery … this elderly patient with bipolar disorder who has received the ECT procedure many times before—he finally

58. Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax | PSNet
    psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
    December 14, 2022 - population, it is not unusual for women to be misdiagnosed for many years as having asthma prior to finally … high rate of recurrence, a pneumothorax in a patient with LAM needs to be managed with pleurodesis, as finally … Finally, clinicians should understand the principles of diagnostic uncertainty as they apply to patients

59. Final Report of the Ockenden Review. | PSNet
    psnet.ahrq.gov/issue/final-report-ockenden-review
    January 13, 2021 - Book/Report Final Report of the Ockenden Review. Citation Text: Final Report of the Ockenden Review. London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294. Copy Citation Save Save to your library Print Download PDF Share Facebook …

60. Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary | PSNet
    psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
    February 26, 2025 - tabulated counts of patient safety reports that fell into each step to quantify where most issues arose. 2 Finally … proactive risk assessments were analyzed together, there were a total of 32 unique failure modes. 2 Finally