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psnet.ahrq.gov/issue/confronting-racism-health-care-moving-proclamations-new-practices
July 31, 2012 - Systems and Providers Can Do. … August 30, 2006
Committed to Safety: Ten Case Studies on Reducing Harm to Patients. … a miscarrying patient. … May 31, 2023
Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment … September 9, 2020
How the pandemic defeated America.
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psnet.ahrq.gov/issue/hospital-board-oversight-quality-and-safety-stakeholder-analysis-exploring-role-trust-and
April 21, 2015 - April 8, 2019
Do hospital boards matter for better, safer, patient care? … and how can these behaviours be reduced? … March 2, 2016
Post event debriefs: a commitment to learning how to better care for patients … November 16, 2015
Exploring the role of communications in quality improvement: a case … study of the 1000 Lives Campaign in NHS Wales.
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psnet.ahrq.gov/issue/safety-leadership-managing-paradox
November 02, 2011 - The author discusses how leaders can help manage the conflicting priorities involved in safety efforts … and uses two case histories to illustrate polarity management principles. … June 8, 2022
How do hospital inpatients conceptualise patient safety? … A qualitative interview study using constructivist grounded theory. … May 31, 2023
Positive approaches to safety: learning from what we do well.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
November 01, 2011 - *
*
Case: Near Miss (3)
The pharmacist came to the ED to teach the patient how to do subcutaneous … near miss
Near misses are unsafe acts that have the potential to injure a patient, but do not
* … , but do not
cause harm
See Notes for references … http://www.jcrinc.com/Books-and-E-books/VNM10/2152/
*
Incidence of Near Misses
It is unclear how … Close calls (near misses) are errors that do not result in harm.
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - Do Not Disturb!. PSNet [internet]. … Do Not Disturb!. PSNet [internet]. … How a physician responds when disturbed from sleep to help a patient is arguably the best test of how … How Can We Predict Professionalism? … Do Not Disturb!. PSNet [internet].
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psnet.ahrq.gov/issue/adaptive-regulation-or-governmentality-patient-safety-and-changing-regulation-medicine
December 09, 2020 - The author conducted an ethnographic study at one British hospital to investigate how policies related … to care home transitions: a retrospective content analysis. … A multisite case study. … August 7, 2019
How organisations contribute to improving the quality of healthcare. … June 12, 2019
Stories from the sharp end: case studies in safety improvement.
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psnet.ahrq.gov/issue/its-all-about-patient-safety-ethnographic-study-how-pharmacy-staff-construct-medicines-safety
October 06, 2021 - Study
'It's all about patient safety': an ethnographic study of how pharmacy staff … ‘It's all about patient safety’: an ethnographic study of how pharmacy staff construct medicines safety … Based on an ethnographic case study of community pharmacies in England, the authors found that polypharmacy … March 31, 2021
How do patients respond to safety problems in ambulatory care? … evaluation of a service designed to improve medication safety for patients with monitored dosage systems
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psnet.ahrq.gov/issue/psychology-insights-apologizing-patients
March 27, 2024 - Apologizing to the patient and family after a harmful event can benefit both patient and provider. … This commentary uses three case studies on apologies to present insights into effective and ineffective … Teaching and role-modeling how to apologize effectively is needed to reestablish trust in the patient-provider … May 15, 2024
How different countries respond to adverse events whilst patients' rights … Do Providers Recover From Errors?
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.128_slideshow.ppt
July 01, 2006 - Accordingly, the TSS score did not signal a need for a nurse or physician to accompany the patient. … How is assessment communicated to the care team, the transport personnel, and destination personnel? … How is compliance monitored? … Would the transport personnel know how to use or troubleshoot any accompanying equipment/supplies, if … Examples of Best Practices
Use of a transport stability scale/tool and develop structure for how, when
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psnet.ahrq.gov/issue/how-well-do-we-communicate-comparison-intraoperative-diagnoses-listed-pathology-reports-and
May 29, 2019 - Study
How well do we communicate? … Citation Text:
Talmon G, Horn A, Wedel W, et al. How well do we communicate? … EndNote 7 XML Endnote tagged PubMedId RIS
Download Citation
Save
Save to … PubMed citation
Available at
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Save to your library
Print
Download PDF … How well do we communicate?
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psnet.ahrq.gov/issue/how-can-interventions-more-directly-address-drivers-unprofessional-behaviour-between
October 09, 2024 - The authors’ program theory (PT) maps drivers and strategies to serve as a basis for developing evidence-based … Download Citation
Related Resources From the Same Author(s)
Why do … A realist review. … A multisite case study. … do we get there?
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
July 01, 2012 - :
Describe current issues with training clinicians to perform procedures
Understand how simulation … can be used to ensure trainees are competent in procedures
Define mastery learning and state how it … While she had not taken a formal ultrasound training course, she had been informally taught how to use … What procedures should internists do? … to a rehabilitation facility 3 weeks later
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - To operate or not to operate? A multi-method analysis of decision-making in emergency surgery. … A surgical safety checklist to reduce morbidity and mortality in a global population. … A study of adverse occurrence and failure to rescue. … Senior physicians are likely to be able to do this more reliably than those with less experience. … How long will the case take?
What is the anticipated blood loss?
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psnet.ahrq.gov/node/47571/psn-pdf
December 12, 2018 - Enhancing safety culture through improved incident
reporting: a case study in translational research … Enhancing Safety Culture Through Improved Incident Reporting: A
Case Study In Translational Research … https://psnet.ahrq.gov/issue/enhancing-safety-culture-through-improved-incident-reporting-case-study- … care provider in London
over a 2-year period to improve incident reporting and optimize its use as … https://psnet.ahrq.gov/issue/enhancing-safety-culture-through-improved-incident-reporting-case-study-translational
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psnet.ahrq.gov/issue/what-role-individual-accountability-patient-safety-multi-site-ethnographic-study
June 16, 2021 - studies to illustrate the fundamental interdependence of systems and individuals at all levels. … case study. … January 19, 2022
How well is quality improvement described in the perioperative care … A vignette study to assess recognition of cognitive biases in clinical case workups. … June 1, 2016
Do clinician disruptive behaviors make an unsafe environment for patients
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psnet.ahrq.gov/issue/how-not-waste-crisis-qualitative-study-problem-definition-and-its-consequences-three
April 21, 2015 - Study
How not to waste a crisis: a qualitative study of problem definition and its … How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals … examine how three distinct hospitals conceived of and acted to improve patient safety. … How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals … October 10, 2018
Do physicians clean their hands?
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psnet.ahrq.gov/issue/using-clinical-simulation-study-how-improve-quality-and-safety-healthcare
March 31, 2021 - Review
Classic
Using clinical simulation to study how to … Using clinical simulation to study how to improve quality and safety in healthcare. … Using clinical simulation to study how to improve quality and safety in healthcare. … March 31, 2021
Why do systems for responding to concerns and complaints so often fail … October 7, 2020
How physicians think: a case-based diagnostic simulation exercise.
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psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
May 01, 2013 - RW : How do we explain that? It feels like a lot of effort has gone into this. … Let's say a hospital figures out how to cut its AMI mortality rate in a meaningful way or figures out … But since we cannot do that, the question is: how do you get everybody else on board? … How concerned are you about that? How good do you think the state of case-mix adjustment is? … I'm fundamentally interested in how do we create a system that lets me deliver better care.
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psnet.ahrq.gov/issue/how-safe-do-dying-people-feel-home-patients-perception-safety-while-receiving-specialist
June 23, 2021 - Study
How safe do dying people feel at home? … How safe do dying people feel at home? … How safe do dying people feel at home? … June 23, 2021
What do patients and their carers do to support the safety of cancer treatment … December 14, 2022
How do patients respond to safety problems in ambulatory care?
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psnet.ahrq.gov/issue/why-do-doctors-make-mistakes-study-role-salient-distracting-clinical-features
July 03, 2014 - Why do doctors make mistakes? A study of the role of salient distracting clinical features. … Why do doctors make mistakes? A study of the role of salient distracting clinical features. … July 3, 2014
Exposure to media information about a disease can cause doctors to misdiagnose … March 12, 2014
Do patients' disruptive behaviours influence the accuracy of a doctor's … March 12, 2014
Teaching about how doctors think: a longitudinal curriculum in cognitive