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Diagnostic error in children presenting with acute medical illness to a community hospital. | PSNet

psnet.ahrq.gov/issue/diagnostic-error-children-presenting-acute-medical-illness-community-hospital

September 25, 2011 - Study Diagnostic error in children presenting with acute medical illness to a community … Diagnostic error in children presenting with acute medical illness to a community hospital. … Diagnostic error in children presenting with acute medical illness to a community hospital. … April 27, 2022 What do emergency department physicians and nurses feel? … April 3, 2019 Autopsy interrogation of emergency medicine dispute cases: how often are

Organisational safety indicators: some conceptual considerations and a supplementary qualitative approach. | PSNet

psnet.ahrq.gov/issue/organisational-safety-indicators-some-conceptual-considerations-and-supplementary-qualitative

August 03, 2016 - limitations of organizational safety indicators and describes the Operational Safety Condition method and how … A qualitative study of barriers to incident reporting among nurses working in nursing homes. … December 19, 2014 A qualitative study of what care workers do to provide patient safety … June 28, 2011 Creating effective quality-improvement collaboratives: a multiple case … study.

Quality and reporting of large-scale improvement programmes: a review of maternity initiatives in the English NHS, 2010–2023. | PSNet

psnet.ahrq.gov/issue/quality-and-reporting-large-scale-improvement-programmes-review-maternity-initiatives-english

February 07, 2024 - October 21, 2020 How to be a very safe maternity unit: an ethnographic study. … A multisite case study. … Enacting a new role to support staff who raise concerns about quality and safety in the English National … Health Service February 19, 2020 Why do systems for responding to concerns and complaints … : a retrospective case study.

Shifting the learning curve. | PSNet

psnet.ahrq.gov/issue/shifting-learning-curve

March 09, 2009 - This article describes how simulation can be used to promote patient safety by helping trainees develop … a mixed methods study of a commonly used quality measure. … December 19, 2018 Developing a process to measure actual harm from medication errors … November 16, 2015 Using Plan Do Study Act to transform a simulation center. … to patient safety: case study involving a labor and delivery ward.

The elephant of patient safety: what you see depends on how you look. | PSNet

psnet.ahrq.gov/issue/elephant-patient-safety-what-you-see-depends-how-you-look

June 22, 2022 - The elephant of patient safety: what you see depends on how you look. … hazards before patients are harmed and, when errors do occur, the optimal methods to recognize them … The elephant of patient safety: what you see depends on how you look. … July 5, 2017 A primer on PDSA: executing plan–do–study–act cycles in practice, not just … to action.

Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know? | PSNet

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July 01, 2017 - reasons that have to do with the strength of the case and how easy it will be to make that case in court … lot of reluctance to do so. … But we ask them to do so in the context of a system that has shifted the standard of care from just imposing … And there are inquiries now about, how do we do this right? … Everybody is going to get there eventually, and the question is how do we prepare for that transition

Results of a survey among GP practices on how they manage patient safety aspects related to point-of-care testing in every day practice. | PSNet

psnet.ahrq.gov/issue/results-survey-among-gp-practices-how-they-manage-patient-safety-aspects-related-point-care

November 21, 2018 - Study Results of a survey among GP practices on how they manage patient safety aspects … Results of a survey among GP practices on how they manage patient safety aspects related to point-of-care … The results of this survey reveal that most primary care practices in the Netherlands do not have adequate … Results of a survey among GP practices on how they manage patient safety aspects related to point-of-care … September 19, 2012 Patient safety measures in burn care: do national reporting systems

When should a leader apologize—and when not? | PSNet

psnet.ahrq.gov/issue/when-should-leader-apologize-and-when-not

October 07, 2020 - The author provides guidance for leaders on when to publicly apologize and how to do so. … April 5, 2017 A program to prevent catheter-associated urinary tract infection in acute … June 8, 2016 A national implementation project to prevent catheter-associated urinary … March 20, 2024 To do no harm - and the most good - with AI in health care. … January 23, 2017 How much diagnostic safety can we afford, and how should we decide?

Communication Error in a Closed ICU | PSNet

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July 01, 2016 - The ICU team therefore chose to place the central line in the right femoral vein and was able to do so … If the intensivists felt that placing lines is what they do and that the surgeons have little to contribute … Rather than working together to understand how such an error could have happened, the ICU team and the … Moreover, debriefs should focus on how cultural norms of the institution might contribute to errors. … July 5, 2023 Prescribing errors in children: why they happen and how to prevent them.

Not-So-Therapeutic Tap | PSNet

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December 01, 2014 - Understand how simulation can be used to ensure trainees are competent in procedures. … Describe mastery learning and how it is relevant to procedural training. … While she had not taken a formal ultrasound training course, she had been informally taught how to use … By neglecting advances in our understanding of how medical trainees learn, educators miss a major opportunity … What procedures should internists do? Ann Intern Med. 2007;146:392-393. [go to PubMed] 3.

Patients' experience of patient safety information and participation in care during a hospital stay. | PSNet

psnet.ahrq.gov/issue/patients-experience-patient-safety-information-and-participation-care-during-hospital-stay

April 05, 2023 - Interventions to increase patient engagement in safety are receiving increasing attention. … In this study, patients were given a safety leaflet containing information about how the patient can … August 25, 2021 Do falls and other safety issues occur more often during handovers when … April 5, 2023 A smartphone app designed to empower patients to contribute toward safer … person- and family-centered care during transitions from hospital to home: a qualitative descriptive

Alarm algorithms in critical care monitoring. | PSNet

psnet.ahrq.gov/issue/alarm-algorithms-critical-care-monitoring

February 03, 2010 - Citation Related Resources From the Same Author(s) Intensive care unit alarms—how … many do we need? … February 3, 2010 Limited health literacy is a barrier to medication reconciliation in … February 24, 2011 Essential elements nurses have to address to promote a safe discharge … May 5, 2010 Intensive care unit alarms—how many do we need?

Medical error: the second victim. | PSNet

psnet.ahrq.gov/issue/medical-error-second-victim-0

February 17, 2017 - Exploring how medical errors affect second victims , this commentary recommends strategies to help them … February 17, 2017 A randomized trial of a multifactorial strategy to prevent serious … December 3, 2014 Case studies of patient safety research classics to build research capacity … June 22, 2017 How to develop a second victim support program: a toolkit for health care … January 15, 2014 Teamwork and team training in the ICU: where do the similarities with

How Professionals Make Decisions. | PSNet

psnet.ahrq.gov/issue/how-professionals-make-decisions

July 06, 2011 - February 21, 2018 Strategies for Hospitals to Improve Patient Safety: A Review of the … the Breadth and Depth of Relationships through National Quantitative Surveys and In-depth Qualitative Case … Studies. … May 21, 2019 Meltdown: Why Our Systems Fail and What We Can Do About It. … A review of the literature.

Impacts of operational failures on primary care physicians' work: a critical interpretive synthesis of the literature. | PSNet

psnet.ahrq.gov/issue/impacts-operational-failures-primary-care-physicians-work-critical-interpretive-synthesis

May 22, 2024 - EndNote 7 XML Endnote tagged PubMedId RIS Download Citation Save Save to … This review synthesized research exploring how operational failures (e.g., distractions , situational … A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame. … A multisite case study. … November 9, 2022 How do patients respond to safety problems in ambulatory care?

Role of clinical context in residents' physical examination diagnostic accuracy. | PSNet

psnet.ahrq.gov/issue/role-clinical-context-residents-physical-examination-diagnostic-accuracy

April 02, 2014 - April 2, 2014 Do you have to re-examine to reconsider your diagnosis? … prospective observational case study of five teaching hospitals. … February 6, 2014 Finding and fixing mistakes: do checklists work for clinicians with … February 6, 2014 Teaching about how doctors think: a longitudinal curriculum in cognitive … November 18, 2013 Do you have to re-examine to reconsider your diagnosis?

Obstetric safety and quality. | PSNet

psnet.ahrq.gov/issue/obstetric-safety-and-quality

October 20, 2014 - improve safety in this setting, including Plan-Do-Study-Act cycles , simulation training , and crew … March 17, 2010 Interdisciplinary collaboration to maintain a culture of safety in a labor … April 27, 2019 What we can do about maternal mortality—and how to do it quickly. … September 1, 2010 In situ simulation: a method of experiential learning to promote safety … threats to patient safety: case study involving a labor and delivery ward.

Bias and racism teaching rounds at an academic medical center. | PSNet

psnet.ahrq.gov/issue/bias-and-racism-teaching-rounds-academic-medical-center

August 12, 2020 - Using four case studies, this article highlights how healthcare professionals can be influenced by biases … , how these biases threaten patient safety, and strategies to mitigate biases and attenuate the impact … RIS Download Citation Related Resources From the Same Author(s) Do … Diagnosis of physical and mental health conditions in primary care during the COVID-19 pandemic: a … December 9, 2020 Physician task load and the risk of burnout among US physicians in a

Getting the Diagnosis Both Right and Wrong | PSNet

psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong

May 29, 2024 - The aforementioned two main types of reasoning—nonanalytic and analytic—do not take place in a vacuum … That is, one must consider the context in which decisions are made in order to understand how those decisions … So how do we improve future decision-making to avoid diagnostic errors such as the tragedy in this case … Situativity theory: a perspective on how participants and the environment can interact: AMEE Guide no … January 16, 2019 How does work environment relate to diagnostic quality?

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care. | PSNet

psnet.ahrq.gov/issue/i-felt-i-was-dying-how-women-postpartum-depression-fall-through-cracks-us-health-care

February 15, 2023 - February 15, 2023 Emergency lights and sirens on ambulances may do more harm than good … June 7, 2023 Hospitals in two states denied an abortion to a miscarrying patient. … May 31, 2023 Why do so many Black women die in pregnancy? … It happened to me, as a pregnant OB-GYN. … August 10, 2022 A crisis within a crisis.

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