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psnet.ahrq.gov/primer/duty-hours-and-patient-safety
June 15, 2024 - decades ago, as recently as 15 years ago, resident physicians routinely worked 90–100 hours per week, for up
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psnet.ahrq.gov/primer/responding-patient-safety-events
October 18, 2023 - Safety-II , where aspects of care that went well are identified and used to standardize and scale up
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psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
April 01, 2010 - Corrigan envisions better aligned and harmonized metrics—that can "roll up and down" among physicians … harmonize measures—for example, to make sure that all of the measures in the area of immunizations follow … RW: I imagine that the never-ending process of coming up with new measures, while dealing with an ever-increasing … Now we're coming up on the decade anniversary of both reports.
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psnet.ahrq.gov/perspective/safety-and-medical-education
December 01, 2013 - advantages of straddling the research and operational line, which is if you can do this work well, it opens up … safety issues were built nicely on our previous sociotechnical approaches to understanding and improving follow-up … having the confidence that if you care, it's an important issue and the world will eventually catch up
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psnet.ahrq.gov/perspective/conversation-chris-cebollero-bs-ccemt-p
May 26, 2021 - I've dropped a patient trying to pick them up and put them on the stretcher. … CC: I think a lot of the organizations, especially the ones that I've worked [with], always set up the … closely aligned with emergency medical services (EMS) care principles: the duty to act, the duty to follow … Preventing medical errors: the bottom-up approach to Just Culture. EMS World. July 16, 2019.
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psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
July 01, 2017 - attorneys are out there trolling around searching and searching to find anyone who could be scraped up … RW : Does that actually come up in court where in the old days, it would have been logical for everyone … That's the notion that we give up on the judicial courts as the primary arbiters for malpractice claims … MM : There are a number of ways you could set this up, but probably the most feasible way for the US … There is more of an evidentiary trail for the plaintiff to obtain and follow.
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psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-disciplinary-actions-and-complaints-what-do-we-know
July 01, 2017 - attorneys are out there trolling around searching and searching to find anyone who could be scraped up … RW : Does that actually come up in court where in the old days, it would have been logical for everyone … MM : There are a number of ways you could set this up, but probably the most feasible way for the US … that we'd like to see is that more who are entitled to compensation under the rules that we've set up … There is more of an evidentiary trail for the plaintiff to obtain and follow.
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psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
January 01, 2018 - RW : Yeah, I'm glad you brought that up in terms of the days of the giants. … You brought up training people as to what represents a useful note in this era. … Let's say it's a heart failure patient, and she'll say, "BUN and creatinine are up a little bit. … I think that the increase in nurse practitioners and physicians' assistants will free up physicians to … time will be spent at the bedside or freed-up time will be spent with more technology.
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psnet.ahrq.gov/web-mm/two-pills-same-drug
May 27, 2011 - Risk
August 1, 2006
WebM&M Cases
Citrate Mix-Up
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psnet.ahrq.gov/node/50612/psn-pdf
October 30, 2019 - The intern looked up the patient on her signout sheet and in the electronic
medical record to check
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psnet.ahrq.gov/node/33886/psn-pdf
August 01, 2019 - Medical scribes: how do their notes stack up? J Fam
Pract. 2016;65:155-159. [go to PubMed]
20.
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psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - Iatrogenic hypoglycemia remains a common yet preventable event in hospitals in the United States, with up
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psnet.ahrq.gov/node/849592/psn-pdf
May 31, 2023 - Still, patients in hospitals fall up to 1 million times per year.7 An estimated 30% of these
falls result
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psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
January 12, 2011 - Up to 40 people per session have been effectively trained in one model ( 2 ), which comports with our
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psnet.ahrq.gov/web-mm/deciphering-code
November 16, 2022 - Finally, there must be adequate back-up systems for managing computer slowdowns and power failures.
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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - The intern and resident cleaned up the materials
from the procedure and left the room. … "(3) Patient falls occur in approximately 2% of hospital stays,
and in the United States up to 1 million … is poor communication of the fall prevention
plan and failure of staff, patients, and families to follow
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - WebM&M Cases
Procedure Complications – Who is Responsible for Follow … up?
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - Attitudes and practices related to clinical alarms: a follow-up survey.
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - Euglycemic DKA is defined as ketoacidosis in the absence of pronounced hyperglycemia and affects up to … These authors recommend providers follow the American College of Obstetricians and Gynecologists’ (ACOG
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - SPOTLIGHT CASE
Failure to Report
Citation Text:
Spath P. Failure to Report. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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