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psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
December 15, 2024 - Moving On Clinicians feel internal and external pressure to "move on," and in the study had three forms
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psnet.ahrq.gov/node/46538/psn-pdf
February 21, 2018 - adverse events occurred frequently, were mostly preventable, and often led to
patient harm in the form
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psnet.ahrq.gov/node/37869/psn-pdf
February 17, 2011 - This national survey of more than 2000 physicians found that only 17% were using any form of
EHR, and
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psnet.ahrq.gov/node/35617/psn-pdf
January 01, 2016 - The authors provide a summary of their safe practice recommendations and share their
reconciliation form
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psnet.ahrq.gov/node/836942/psn-pdf
April 27, 2022 - minimized through strict
adherence to use of pre-printed labels with the name of the medication, its form … should be administered without a complete label, defined as
listing the name of the medication, its form … No medication should be administered without a complete label, defined as listing its name, form
and
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psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
June 24, 2020 - just culture balances accountability with learning.( 1 ) What we see here is only (one very narrow form … In this lipid overdose case, the response can easily be seen as unjust: only (one narrow form of) accountability
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psnet.ahrq.gov/node/44444/psn-pdf
September 02, 2015 - Clinical communities at Johns Hopkins Medicine: an
emerging approach to quality improvement.
September 2, 2015
Gould LJ, Wachter PA, Aboumatar HJ, et al. Clinical Communities at Johns Hopkins Medicine: An
Emerging Approach to Quality Improvement. Jt Comm J Qual Patient Saf. 2015;41(9):387-395.
https://psnet.ahrq.g…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
May 01, 2010 - This case demonstrates a very narrow form of accountability and no learning—a lost opportunity
* … failure with accountability for failure
In this case, the response seems unjust: only (one narrow form
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psnet.ahrq.gov/node/49448/psn-pdf
June 01, 2004 - prevented 75%, proper marking of the site would have prevented 65%, and a properly completed
consent form … In other cases, indicated by checking the respective boxes on the
form (Figure 2), the attending must … Sample Form for Preoperative Checklist
Click on the thumbnail for a full view of Figure 2.
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psnet.ahrq.gov/node/47812/psn-pdf
April 17, 2019 - Risk aversion in clinical practice may lead to the ordering of unnecessary tests and procedures, a form
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psnet.ahrq.gov/node/43651/psn-pdf
November 18, 2016 - Ebola US Patient Zero: lessons on misdiagnosis and
effective use of electronic health records.
November 18, 2016
Upadhyay DK, Sittig DF, Singh H. Ebola US Patient Zero: lessons on misdiagnosis and effective use of
electronic health records. Diagnosis (Berl). 2014;1(4):283-287. doi:10.1515/dx-2014-0064.
https://psn…
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psnet.ahrq.gov/node/36867/psn-pdf
August 31, 2011 - Using a newly designed form, investigators developed a system of shared ownership among
nurses, pharmacists
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psnet.ahrq.gov/node/38010/psn-pdf
August 27, 2008 - Detection of adverse events in surgical patients using the
Trigger Tool approach.
August 27, 2008
Griffin FA, Classen DC. Detection of adverse events in surgical patients using the Trigger Tool approach.
Qual Saf Health Care. 2008;17(4):253-258. doi:10.1136/qshc.2007.025080.
https://psnet.ahrq.gov/issue/detection-…
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psnet.ahrq.gov/node/37849/psn-pdf
March 23, 2011 - The incidence and nature of in-hospital adverse events: a
systematic review.
March 23, 2011
de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse
events: a systematic review. Qual Saf Health Care. 2008;17(3):216-223. doi:10.1136/qshc.2007.023622.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/web-mm/wrongful-resuscitation
October 12, 2012 - After his recovery, he completed a DNR (do not resuscitate) form signifying his desire to avoid such … Although his DNR form was with him, neither the ED staff nor the consulting surgeon looked at it. … Postoperatively, an internist came upon the DNR form in the patient's chart and discussed resuscitation … older nursing home resident is transferred to an acute care setting, not only should an interagency form
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psnet.ahrq.gov/node/49496/psn-pdf
December 01, 2005 - companions rather than patients), compromising patient privacy
(eg, by helping patients to complete written forms
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psnet.ahrq.gov/node/45535/psn-pdf
January 23, 2017 - near-misses
Errors related to the handling of surgical specimens can lead to serious patient harm in the form
-
psnet.ahrq.gov/node/42898/psn-pdf
January 29, 2014 - Association of sleep and fatigue with decision regret
among critical care nurses.
January 29, 2014
Scott LD, Arslanian-Engoren C, Engoren MC. Association of sleep and fatigue with decision regret among
critical care nurses. Am J Crit Care. 2014;23(1):13-23. doi:10.4037/ajcc2014191.
https://psnet.ahrq.gov/issue/ass…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
July 01, 2011 - educated patient and caregiver regarding warfarin management
Could have used standardized education forms
-
psnet.ahrq.gov/node/33869/psn-pdf
November 01, 2018 - But some forms of care coordination need go away in a model like this, because
as a Comprehensive Care … But I also truly believe there are incredible forms of satisfaction. … This is a form of hospitalists, and it's a
reflection of the evolution of the model rather than a departure … It is a form of hospital medicine that has
evolved in the context of the evolution of the field. … hospitalization who would switch
fully into this model, or to partner with ambulatory practices using some form