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

2261. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49387/psn-pdf
      February 01, 2003 - He was scheduled to receive a dose of IV haloperidol at 7AM. … accounts for about 15% of all inpatients at UCSF) to see how often there were identical last names over … It is also important to remember that these 'flukes' do happen, and the thousands of medication administrations … If the codes do not match, the nurse is alerted to the possibility of an error. … Do not allow patients with similar or the same names to be placed in the same room (ideally, they would

2262. In Conversation With… Maureen Bisognano | PSNet
      psnet.ahrq.gov/perspective/conversation-maureen-bisognano
      February 26, 2025 - How did the work change when To Err Is Human came out and all of a sudden it became a big national … And, "How do we best deal with them?" … How much of that do you see as an enabler? … How do you navigate that? … How do you think about that? MB : There's a formula that I walk around with in my head.

2263. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49450/psn-pdf
      June 01, 2004 - Clinicians may appreciate that error disclosure is "the right thing to do" but experience insurmountable … Patients especially value understanding how an error happened and how recurrences will be prevented, … Determining exactly how an error happened and formulating a plan for preventing recurrences can be especially … Do house officers learn from their mistakes? JAMA. 1991;265:2089-94.[ go to PubMed ] 10. … Why do people sue doctors? A study of patients and relatives taking legal action.

2264. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33747/psn-pdf
      March 01, 2013 - the opportunity it provides to rehearse skills in a risk-free environment, to engage in repeated and … Having established that simulation works, the next question may be, How does simulation compare with … This raises a third question: Why are some simulation interventions better than others (and how can … faculty time, training expenses, facility fees, and opportunity costs (i.e., what else could trainees do … However, much remains to be learned about how to optimally implement simulation-based education.

2265. Maternal Safety | PSNet
      psnet.ahrq.gov/primer/maternal-safety
      January 10, 2024 - Patient Safety Threats and Challenges As research evolves and begins to recognize nationally how historic … hear the stories and threats to safety and understand how to provide consistently safe access and equitable … or do not receive the right care quickly enough in an emergency. … Deaths: A Guide for Moving Maternal Mortality Review Committee Data to Action to help organizations … The cycle to respectful care: a qualitative approach to the creation of an actionable framework to address

2266. In Conversation with...Steven J. Spear, DBA, MS, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
      August 01, 2009 - what to do is a profound misunderstanding. … So if a nurse goes to pour meds and there's a med missing, what does she do? … and they kept saying, "How do we engage the front line?" … The way to phrase the reform question is: How do you provide better care to more people in less time … What can organizations do to move from a workaround culture to a culture that uses operational failures

2267. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49467/psn-pdf
      December 01, 2004 - a reticent patient with a question like: "What do you mean by 'weak'?" … Even in the absence of technology, many patients know how, or can be quickly taught, to take their pulse … should do if the weakness persisted or increased, or what other symptoms should prompt a call. … he still was weak, or called the patient back a few hours later to see how he felt. … The question should be whether the patient needs emergency evaluation, and if not, to determine how

2268. Five system barriers to achieving ultrasafe health care. | PSNet
      psnet.ahrq.gov/issue/five-system-barriers-achieving-ultrasafe-health-care
      September 29, 2017 - not at a calculated and accepted risk. … September 29, 2017 Adverse events in medicine: easy to count, complicated to understand … , and complex to prevent. … a taxonomy of adaptive strategies. … November 6, 2024 How to do no harm: empowering local leaders to make care safer in low-resource

2269. Does an app a day keep the doctor away? AI symptom checker applications, entrenched bias, and professional responsibility. | PSNet
      psnet.ahrq.gov/issue/does-app-day-keep-doctor-away-ai-symptom-checker-applications-entrenched-bias-and
      March 14, 2018 - Commentary Does an app a day keep the doctor away? … Does an app a day keep the doctor away? … This article discusses AI-powered symptom check apps and how implicit and explicit biases (e.g., health … Does an app a day keep the doctor away? … May 15, 2024 To do no harm - and the most good - with AI in health care.

2270. Multidisciplinary approaches to reducing error and risk in a patient care setting. | PSNet
      psnet.ahrq.gov/issue/multidisciplinary-approaches-reducing-error-and-risk-patient-care-setting
      January 05, 2017 - Multidisciplinary approaches to reducing error and risk in a patient care setting. … The authors share how a single adverse event catalyzed 7 years of efforts to bring patient safety to … Multidisciplinary approaches to reducing error and risk in a patient care setting. … January 2, 2017 A randomized trial of a multifactorial strategy to prevent serious fall … January 28, 2010 WebM&M Cases Do Not Disturb!

2271. Patients as diagnostic collaborators: sharing visit notes to promote accuracy and safety. | PSNet
      psnet.ahrq.gov/issue/patients-diagnostic-collaborators-sharing-visit-notes-promote-accuracy-and-safety
      April 15, 2020 - This commentary summarizes research on how sharing notes with patients can improve the timeliness of … follow-up to confirm a diagnosis, identify documentation errors , and strengthen communication between … A PSNet interview discussed use of OpenNotes to engage patients in their care. … June 7, 2023 COVID-19 and open notes: a new method to enhance patient safety and trust … December 18, 2014 Do patients who read visit notes on the patient portal have a higher

2272. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867986/psn-pdf
      March 24, 2025 - If they are positive, how often do we reassess their risk to monitor them over time? … They have been using evidence-based screenings, they have trained their personnel on how to do a good … This will clearly delineate how to do the screening, when to do the screening, what screener you are … Make sure everyone on the team is trained and practiced in how to do it. … do and are well-trained in how to do it.

2273. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49728/psn-pdf
      March 01, 2015 - month, this can add up to a significant hazard. … to a barcode medication administration (BCMA) system. … , therefore, considered to have a minimal impact. … How many hospital pharmacy medication dispensing errors go undetected? … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2274. African Partnerships for Patient Safety: Lessons Learned | PSNet
      psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
      December 01, 2014 - How do we roll out programs that are relevant across the board for those scale variations within the … How do you even begin thinking about that issue of scale and spread given the size and variation in your … have the same issues around staff motivation, too many patients, how to get people to do the right thing … How important is it to have an internationally recognized champion to give these programs a face? … So is that part of what we're trying to do, and if we are, how does that infrastructure get built?

2275. Antibiotic and Opioid Stewardship in Dentistry | PSNet
      psnet.ahrq.gov/perspective/antibiotic-and-opioid-stewardship-dentistry
      December 07, 2020 - how we needed to standardize the services that we were providing. … In general, dental practices also do not have access to a comprehensive electronic medical history. … If they do, do they know how to use it? … I believe that study was limited to one state, but she did do a national survey of the National Dental … For example, for a long time there's been a sink next to the dental chair, how long did it take us to

2276. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33833/psn-pdf
      May 01, 2017 - How do you think that folds into this narrative about how things got out of hand with opioids? … But the right thing to do is to have a difficult conversation. … That's a reflection of how these can be self-perpetuating. … It was a message that we were conditioned by nature to hear because of how much we want to help people … If your goal as a doctor is to help more than harm, we need to seriously rethink how we prescribe opioids

2277. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units | PSNet
      psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
      April 26, 2023 - Thus, finding someone unresponsive when you come in to do vital signs or give a medication happens more … Your brain is designed to do that, to filter out noise. … As far as early warning and risk scores, we do think these can be used to identify people who need to … To do that, you need to design the system to detect a deviation that’s more severe and more sustained … We know that is a vulnerability: new people not understanding the system, its rationale, and how to use

2278. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851568/psn-pdf
      July 31, 2023 - Authors, reviewers and others in a position to control the content of this activity are required to … Articulate how to minimize clinician bias in assessment of substance use disorders. … These medications control autonomic hyperactivity and decrease sympathetic activation; however, they do … Free text communication is a type of order that providers can use to instruct nurses about how to titrate … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2279. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49460/psn-pdf
      September 01, 2004 - error, is confronted with the problem of if, and how, to report it. … a decision, reasoning that "It seemed wrong, but what do I know?" … This particular case emphasizes the issue of a student not knowing what to do. … their own when deciding how to report and to whom. … a case like this one, students should be oriented to an "error ombudsman"—someone who knows how to

2280. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33703/psn-pdf
      November 01, 2010 - 2,3,6-8) In this article, I will review the present state of patient safety measurement, reflecting on how … and fail to provide information on the true rate of a particular safety event for a given population … To Err is Human: Building a Safer Health System. … [go to PubMed] 10. Brown C, Hofer T, Johal A, et al. … Evaluating the patient safety indicators: how well do they perform on Veterans Health Administration