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psnet.ahrq.gov/classics
August 01, 2023 - Reconciliation
(14)
Read Back Protocols
(7)
SBAR
(4)
Structured Hand-offs … Error
(6)
Radiograph Interpretation Error
(7)
Discontinuities, Gaps, and Hand-Off
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
January 01, 2022 - Dermatitis. 17:270-275 1987 PMID: 2963724
34.Wang WL, Kelly KJ, Klancnik M, Petsonk EL: Self-reported hand … Self-reported hand symptoms-a role in monitoring health care workers for latex sensitization?
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psnet.ahrq.gov/issue/occurrence-potential-patient-safety-events-among-trauma-patients-are-they-random
July 19, 2018 - Study
The occurrence of potential patient safety events among trauma patients: are they random?
Citation Text:
Chang DC, Handly N, Abdullah F, et al. The occurrence of potential patient safety events among trauma patients: are they random? Ann Surg. 2008;247(2):327-34. doi:10.1097/SLA.…
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - You can just put your hand up or shake your head, "I'm on the phone," that sort of thing. … Imagine if before I touch a patient, "Please wash your hands," flashes up on the screen of the glasses … background once technology focuses on the physical context, the people around you, and the task at hand … Typically only a smattering of audience members will raise their hands. … January 1, 2015
Perspective
Innovations in Promoting Hand
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psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
August 01, 2007 - "Hey, just look at this wonderful stuff we just did," they'd hear"A patient lost their hand in a farm … When boards look at finance, they look at the operating margin, they look at days of cash on hand, they … And it's not surprising that they throw their hands up. They can't sort the wheat from the chaff.
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psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - A coach sits on his or her hands. … A coach does not grab the phone out of the patient's hand and make phone calls, but rather models the … Providers
Health Care Executives and Administrators
Gynecology
Discontinuities, Gaps, and Hand-Off
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psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
February 01, 2007 - Automatic, subconscious cognition matches up the features of the case at hand with one or more of these … arrive at their initial diagnostic choicesthese are the first possibilities that fit the facts at hand … Surprisingly, "fast and frugal" decisions are highly accurate, especially in the hands of experts.( 4
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psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
August 01, 2007 - "Hey, just look at this wonderful stuff we just did," they'd hear"A patient lost their hand in a farm … When boards look at finance, they look at the operating margin, they look at days of cash on hand, they … And it's not surprising that they throw their hands up. They can't sort the wheat from the chaff.
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psnet.ahrq.gov/node/837784/psn-pdf
August 05, 2022 - , we want to have only the safest and the
most user-friendly technology make it into the patient’s hands … Privacy and security often go hand in hand, but
security is more about protection from external threats
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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - A coach sits on his or her hands. … A coach does not grab the phone out of the patient's hand and make phone calls, but rather models the … Providers
Health Care Executives and Administrators
Gynecology
Discontinuities, Gaps, and Hand-Off
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psnet.ahrq.gov/perspective/conversation-withjack-barker-phd
January 01, 2006 - surgery felt empowered to actually speak up when one individual sneezed and then, without washing his hands … Then this person who sneezed said, "Okay, yeah, you're right, I need to go wash my hands," and did it … On one hand, this heterogeneity may impede information sharing and learning, but it also may result in
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psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
March 01, 2014 - Semmelweiss showed that providers could protect mothers from death during childbirth by washing their hands … and Protocols
Hospital policies related to infection prevention
Compliance monitoring (e.g., hand … January 1, 2015
Perspective
Innovations in Promoting Hand
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psnet.ahrq.gov/perspective/telemedicine-and-patient-safety
September 01, 2016 - Proctor Harvey , a cardiologist who taught me the value and importance of laying on hands. … On the one hand, as we look at the role of our state medical boards, these are well-meaning and good … They'll be able to package that information, hand it to the physician in a digested way, and give doctors
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psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md
September 01, 2016 - Proctor Harvey , a cardiologist who taught me the value and importance of laying on hands. … On the one hand, as we look at the role of our state medical boards, these are well-meaning and good … They'll be able to package that information, hand it to the physician in a digested way, and give doctors
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psnet.ahrq.gov/node/33669/psn-pdf
May 01, 2018 - Too often, in our desire to get information tools into the hands of users, we have skipped one or more
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - facilities may be spread across a wide geographic area – creating a condition where samples exchange hands … The most common causes of errors were hand-off communication problems, staff inattention, knowledge deficit
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - there is obvious safety benefit of taking these complex weight-based treatment calculations out of the hands … If the clinician had to type, or write by hand, the weight of 25 kilograms, or 55 pounds, rather than
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - call for additional help via an overhead paging system (e.g., “code blue”) is critical to have extra hands … In the setting of an obese patient who has vomited, two hand mask ventilation technique is likely needed
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psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
March 01, 2009 - The issue at hand is the success with which our health care system more broadly guides patients regarding … Due to the advent of e-prescribing, this step may be taken out of the physician's hands, with default
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psnet.ahrq.gov/issue/hospitals-boost-patients-power-advisers
August 17, 2016 - June 25, 2014
Why hospitals want patients to ask doctors, 'Have you washed your hands … October 14, 2015
Why hospitals want patients to ask doctors, 'Have you washed your hands