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Showing results for "how to do a case study".

101. Do no harm: hospital care in Las Vegas. | PSNet
     psnet.ahrq.gov/issue/do-no-harm-hospital-care-las-vegas
     October 02, 2013 - Citation Text: Do no harm: hospital care in Las Vegas. Allen M; Richards A. … Allen M; Richards A. … Copy Citation Related Resources From the Same Author(s) How many die from … January 23, 2013 How hepatitis probe led to clinic: old-fashioned legwork yielded clues … March 21, 2011 First do no harm.

102. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
     June 01, 2005 - analysis Case: Getting to the Root of the Matter A 65-year-old man with atrial fibrillation, … Performing Root Cause Analysis How would you do it? … Medication reconciliation: a practical tool to reduce the risk of medication errors. … Do house officers learn from their mistakes? JAMA. 1991;265:2089-2094. … Do house officers learn from their mistakes? JAMA. 1991;265:2089-2094.

103. Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection. | PSNet
     psnet.ahrq.gov/issue/graduate-medical-education-and-patient-safety-busy-and-occasionally-hazardous-intersection
     March 02, 2011 - This case study presents the events surrounding the death of a woman admitted to an academic medical … February 3, 2011 Work hour rules and contributors to patient care mistakes: a focus group … July 2, 2008 How do hospitalized patients feel about resident work hours, fatigue, and … November 16, 2011 A program to prevent catheter-associated urinary tract infection in … March 4, 2019 Leveraging the continuum: a novel approach to meeting quality improvement

104. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
     December 01, 2004 - For example, if a hospitalist fails to arrange appropriate follow-up for a patient with a solitary pulmonary … What the Patient Can do to Improve Safety at Discharge Understand important new health problems and … events Arrange home nursing visits What the System can do to Improve Safety at Discharge In-hospital … Do you know which of your home medications to continue, what the current doses are, and which you should … do if things are not going well Confirm that patient comprehends your instructions Include a family

105. Evaluation of a measurement system to assess ICU team performance. | PSNet
     psnet.ahrq.gov/issue/evaluation-measurement-system-assess-icu-team-performance
     November 17, 2014 - Evaluation of a Measurement System to Assess ICU Team Performance. … Evaluation of a Measurement System to Assess ICU Team Performance. … November 17, 2014 A systematic review of teamwork in the intensive care unit: what do … February 8, 2017 Unreported errors in the intensive care unit: a case study of the way … December 22, 2010 How RNs rescue patients: a qualitative study of RNs' perceived involvement

106. Do clinicians know which of their patients have central venous catheters?: A multicenter observational study. | PSNet
     psnet.ahrq.gov/issue/do-clinicians-know-which-their-patients-have-central-venous-catheters-multicenter
     June 08, 2016 - Study Do clinicians know which of their patients have central venous catheters? … Do clinicians know which of their patients have central venous catheters? … Do clinicians know which of their patients have central venous catheters? … December 21, 2017 How physicians think: a case-based diagnostic simulation exercise. … October 13, 2018 Mind the overlap: how system problems contribute to cognitive failure

107. Is "first do no harm" a lost concept in medical education? | PSNet
     psnet.ahrq.gov/issue/first-do-no-harm-lost-concept-medical-education
     December 01, 2004 - Commentary Is "first do no harm" a lost concept in medical education? … Is "first do no harm" a lost concept in medical education. MedGenMed. 2006;8(3):77. … to improve teamwork and quality for hospitalized patients: a multi-site qualitative comparative case … study. … December 16, 2009 Reflection and analysis of how pharmacy students learn to communicate

108. How will we know patients are safer? An organization-wide approach to measuring and improving safety. | PSNet
     psnet.ahrq.gov/issue/how-will-we-know-patients-are-safer-organization-wide-approach-measuring-and-improving-safety
     May 20, 2009 - The authors discuss a measurement approach that focuses on the following: how often do we harm patients … , how often do patients receive the appropriate interventions, how do we know we learned from defects … , and how well have we created a culture of safety. … Building on a model of structure, process, and outcome measures used to evaluate health care quality, … They provide a case-type example of their suggested process to illustrate their framework.

109. Emergency Error | PSNet
     psnet.ahrq.gov/web-mm/emergency-error
     January 18, 2013 - Describe how variability in processes of care can increase the risk to patients undergoing emergency … , and Plan-Do-Study-Act cycles. … Decisions about how, when, and whether to operate emergently are complex and based largely on experience … be undertaken and, in the case study above, may have increased awareness of the risk of sudden deterioration … Senior physicians are likely to be able to do this more reliably than those with less experience.

110. Managing the Unexpected: Sustained Performance in a Complex World, Third Edition. | PSNet
     psnet.ahrq.gov/issue/managing-unexpected-sustained-performance-complex-world-3rd-edition
     November 04, 2015 - The authors, professors at the University of Michigan School of Business, use both case studies and theory-based … analysis to explain the methods that result in organizational mindfulness, and, through it, a more robust … What Do We Do? … August 16, 2016 To Do No Harm: Ensuring Patient Safety in Health Care Organizations. … test new healthcare facilities: a proactive and innovative approach to healthcare system safety.

111. How two rights can make a wrong. | PSNet
     psnet.ahrq.gov/issue/how-two-rights-can-make-wrong
     November 09, 2016 - Newspaper/Magazine Article How two rights can make a wrong. … Citation Text: How two rights can make a wrong. Markel H. … two rights can make a wrong. … October 5, 2016 Measurement of diagnostic errors is a key first step to their reduction … June 13, 2011 What drugs do you take?

112. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49654/psn-pdf
     June 01, 2012 - Describe how communication lapses can lead to errors and adverse events in the transfer of patients … Although it is difficult to accurately determine how many patients are transferred each year worldwide … In addition to these emergent transfers, many transfers do involve medically stable patients and are … transport services–a case study. … Do specialist transport personnel improve hospital outcome in critically ill patients transferred to

113. The frustrating case of incident-reporting systems. | PSNet
     psnet.ahrq.gov/issue/frustrating-case-incident-reporting-systems
     June 22, 2022 - This commentary discusses the limitations of incident reporting systems and provides suggestions for how … to identify adverse events. … A prospective observational cohort. … July 5, 2017 A primer on PDSA: executing plan–do–study–act cycles in practice, not just … September 29, 2021 Teaching medical error disclosure to physicians-in-training: a scoping

114. Positive approaches to safety: learning from what we do well. | PSNet
     psnet.ahrq.gov/issue/positive-approaches-safety-learning-what-we-do-well
     September 15, 2021 - Positive approaches to safety: learning from what we do well. … September 15, 2021 A qualitative study of what care workers do to provide patient safety … December 14, 2022 How do hospital inpatients conceptualise patient safety? … March 24, 2021 How do patients respond to safety problems in ambulatory care? … 1,500 avoidable deaths a year—and aim to do even better.

115. Do you have to re-examine to reconsider your diagnosis? Checklists and cardiac exam. | PSNet
     psnet.ahrq.gov/issue/do-you-have-re-examine-reconsider-your-diagnosis-checklists-and-cardiac-exam
     February 06, 2014 - Study Do you have to re-examine to reconsider your diagnosis? … Do you have to re-examine to reconsider your diagnosis? Checklists and cardiac exam. … An AHRQ WebM&M commentary discusses a missed physical examination finding that led to a diagnostic … Do you have to re-examine to reconsider your diagnosis? Checklists and cardiac exam. … April 10, 2019 Comfort with uncertainty: reframing our conceptions of how clinicians

116. Communication failures: an insidious contributor to medical mishaps. | PSNet
     psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps
     February 24, 2011 - Several anecdotes illustrate the role communication failures played in these mishaps and how common these … November 1, 2023 Primary care teams' reported actions to improve medication safety: a … case study. … step toward high reliability: implementation of a daily safety brief in a children's hospital. … December 30, 2014 Hospital do-not-resuscitate orders: why they have failed and how to

117. A case of mistaken identity: staff input on patient ID errors. | PSNet
     psnet.ahrq.gov/issue/case-mistaken-identity-staff-input-patient-id-errors
     March 27, 2024 - A case of mistaken identity: staff input on patient ID errors. … May 27, 2011 The mindful path to nursing accuracy: a quasi-experimental study on minimizing … February 21, 2018 What do we really know about crew resource management in healthcare … A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic … January 29, 2020 The wicked problem of patient misidentification: how could the technological

118. Technology as a Tool for Improving Patient Safety | PSNet
     psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
     April 26, 2023 - A case study last year Illustrated one of the technological issues, in this case a manual keystroke … A study on “do not give” alerts found that clinicians modified their orders to comply with alert recommendations … Second, more work is needed on system usability, how the systems are integrated into workflows, and how … For example, when a scribe encounters a CDS alert, do they alert the clinician in all cases?  … a case study using the UP-Fall detection dataset.

119. Safety as a criterion for quality: The Critical Nursing Situation Index in paediatric critical care, an observational study. | PSNet
     psnet.ahrq.gov/issue/safety-criterion-quality-critical-nursing-situation-index-paediatric-critical-care
     March 01, 2011 - March 6, 2019 Informal learning from error in hospitals: what do we learn, how do we … learn and how can informal learning be enhanced? … A narrative review. … a case study with unplanned extubations. … January 23, 2019 Failure to rescue in neonatal care.

120. Special Edition Perspective: Technology Responses to COVID-19 | PSNet
     psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19
     August 31, 2020 - series of case studies from interviews and written responses from leaders at three different health systems … [4]   The three case studies presented below from UC Davis Medical Center, University of Arkansas for … Case Studies To develop these case studies, the sites responded to a series of questions that gathered … But how do you work with your patients to ensure that they are comfortable with doing a telehealth visit … Conclusion   All three case studies highlighted in this Perspective demonstrate innovative ways that