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

241. Hard to Swallow | PSNet
     psnet.ahrq.gov/web-mm/hard-swallow
     April 26, 2023 - How can we be sure that important patient information is communicated and received? … do the same. … At a deeper level, physicians need to make sure they do not contribute to a culture in which non-physician … How the medical record was organized in this case is not unusual, nor is the illusion that certain parts … Why do people sue doctors? A study of patients and relatives taking legal action.

242. Using root cause analysis to reduce falls with injury in the psychiatric unit. | PSNet
     psnet.ahrq.gov/issue/using-root-cause-analysis-reduce-falls-injury-psychiatric-unit
     September 18, 2019 - Citation Text: Lee A, Mills PD, Watts B. … Using root cause analysis to reduce falls with injury in the psychiatric unit. … Using root cause analysis to reduce falls with injury in the psychiatric unit. … September 5, 2018 How well do incident reporting systems work on inpatient psychiatric … conflicts: review of case reports from a national Veterans Affairs database.

243. A Costly Colonoscopy Leads to a Delay in Diagnosis | PSNet
     psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
     September 01, 2014 - A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. … a screening colonoscopy, ask your insurance company how much (if anything) you should expect to pay … Physicians may (quite reasonably) argue that they do not have the time or expertise to help patients … and determine how best to address them. … [go to PubMed] 9. Moriates C, Shah NT, Arora VM. First, do no (financial) harm.

244. Prescribing errors in children: why they happen and how to prevent them. | PSNet
     psnet.ahrq.gov/issue/prescribing-errors-children-why-they-happen-and-how-prevent-them
     December 13, 2017 - Citation Text: Conn R, Fox A, Carrington A, et al. … Prescribing errors in children: why they happen and how to prevent them. … Carrington A, et al. … Prescribing errors in children: why they happen and how to prevent them. … July 25, 2012 Hospital do-not-resuscitate orders: why they have failed and how to fix

245. Improving medical residents’ self-assessment of their diagnostic accuracy: does feedback help? | PSNet
     psnet.ahrq.gov/issue/improving-medical-residents-self-assessment-their-diagnostic-accuracy-does-feedback-help
     September 14, 2022 - December 1, 2021 Do malpractice claim clinical case vignettes enhance diagnostic accuracy … November 16, 2022 A program to provide clinicians with feedback on their diagnostic performance … October 28, 2020 Thresholds, rules and defensive strategies: how physicians learn from … August 21, 2019 The design and conduct of Project RedDE: a cluster-randomized trial to … August 25, 2011 WebM&M Cases Do Not Disturb!

246. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49603/psn-pdf
     June 01, 2010 - Identify best sources of information for designing a response to an error. … very few nurses come to work to do a bad job. … Do three things to determine why it made sense for the nurse to do what he or she did. … How do hospitals manage these kinds of errors in general? Not very impressively. … This, in the end, is how a hospital can balance accountability and learning.

247. Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature. | PSNet
     psnet.ahrq.gov/issue/ten-challenges-improving-quality-healthcare-lessons-health-foundations-programme-evaluations
     February 19, 2020 - Health Service February 19, 2020 Why do systems for responding to concerns and complaints … A multisite case study. … June 16, 2021 How well is quality improvement described in the perioperative care literature … April 29, 2015 How not to waste a crisis: a qualitative study of problem definition and … June 28, 2017 Dual-process cognitive interventions to enhance diagnostic reasoning: a

248. Successful implementation of standardized multidisciplinary bedside rounds, including daily goals, in a pediatric ICU. | PSNet
     psnet.ahrq.gov/issue/successful-implementation-standardized-multidisciplinary-bedside-rounds-including-daily-goals
     September 03, 2011 - This study describes how a pediatric intensive care unit applied a multidisciplinary approach to rounds … prospective observational case study of five teaching hospitals. … November 8, 2013 Improving teamwork on general medical units: when teams do not work … face-to-face. … : A survey of practices and recommendations.

249. Seven features of safety in maternity units: a framework based on multisite ethnography and stakeholder consultation. | PSNet
     psnet.ahrq.gov/issue/seven-features-safety-maternity-units-framework-based-multisite-ethnography-and-stakeholder
     February 20, 2019 - The researchers used qualitative methods to generate a new plain language framework identifying safe … Several  synergistic features  were identified including a commitment to  safety culture ; technical … to be a very safe maternity unit: an ethnographic study. … A multisite case study. … June 7, 2021 - June 8, 2021 First do no harm: practitioners' ability to 'diagnose'

250. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33796/psn-pdf
     January 01, 2016 - How strategic were you in the beginning? Did you say we need to do this, this, and this? … How can we do a better job getting our patients access to care? … How can we do a better job making sure all the lab tests reach the right people who need to know? … We could start in medical school to ask students, how well do you think you're going to do on this test … You get so much more information from watching how a clinician analyzes a case than you do from how

251. The good, the bad and the ugly: what do we really do when we identify the best and the worst organisations?. | PSNet
     psnet.ahrq.gov/issue/good-bad-and-ugly-what-do-we-really-do-when-we-identify-best-and-worst-organisations
     August 20, 2018 - Commentary The good, the bad and the ugly: what do we really do when we identify … The good, the bad and the ugly: what do we really do when we identify the best and the worst organisations … The good, the bad and the ugly: what do we really do when we identify the best and the worst organisations … July 1, 2017 View More Related Resources How can specialist investigation … A qualitative study of perspectives on the early years of the English Healthcare Safety Investigation

252. From patients to politicians: a cognitive engineering view of patient safety. | PSNet
     psnet.ahrq.gov/issue/patients-politicians-cognitive-engineering-view-patient-safety
     January 29, 2020 - From patients to politicians: a cognitive engineering view of patient safety. … Vicente emphasizes looking at all levels of a hierarchy and how research should be integrated vertically … From patients to politicians: a cognitive engineering view of patient safety. … A case study of radical change toward patient safety. … June 14, 2019 Meltdown: Why Our Systems Fail and What We Can Do About It.

253. Testing the association between Patient Safety Indicators and hospital structural characteristics in VA and nonfederal hospitals. | PSNet
     psnet.ahrq.gov/issue/testing-association-between-patient-safety-indicators-and-hospital-structural-characteristics
     April 01, 2010 - Citation Text: Rivard PE, Elixhauser A, Christiansen CL, et al. … April 1, 2010 Evaluating the Patient Safety Indicators: how well do they perform on Veterans … hospital performance: a VA case study. … January 3, 2017 Partnering with VA stakeholders to develop a comprehensive patient safety … 2013 Validating the Patient Safety Indicators in the Veterans Health Administration: do

254. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture | PSNet
     psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
     March 15, 2023 - Describe how tracheostomy teams, staff education and cuff monitoring protocols help to avoid tracheostomy … On inspection, the tracheal cuff had burst, leading to a severe leak in addition to a tracheal tear with … when safe to do so. … Failure to do so can lead to tracheal and surrounding structure damage with severe clinical consequences … events: a case study with unplanned extubations.

255. The impact of the 80-hour work week on appropriate resident case coverage. | PSNet
     psnet.ahrq.gov/issue/impact-80-hour-work-week-appropriate-resident-case-coverage
     June 18, 2008 - The newly proposed resident work hour regulations do not call for further reductions in duty hours, … January 27, 2019 How hospitals select their patient safety priorities: an exploratory … September 25, 2019 Partnering with VA stakeholders to develop a comprehensive patient … a simulated surgical procedure. … February 18, 2011 A new professionalism?

256. As she lay dying: how I fought to stop medical errors from killing my mom. | PSNet
     psnet.ahrq.gov/issue/she-lay-dying-how-i-fought-stop-medical-errors-killing-my-mom
     December 19, 2012 - Commentary As she lay dying: how I fought to stop medical errors from killing my … As she lay dying: how I fought to stop medical errors from killing my mom. … As she lay dying: how I fought to stop medical errors from killing my mom. … June 27, 2012 Why do hospital prescribers continue antibiotics when it is safe to stop … 1,500 avoidable deaths a year—and aim to do even better.

257. If You Say So: Taking a Syringe at Face Value in the Operating Room | PSNet
     psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
     January 01, 2015 - is ineffective.( 8 ) Furthermore, a recent in-depth case study demonstrated that even organizations … Educating junior or less powerful staff on how to speak up cannot overcome an organizational culture … [go to PubMed] 7. Lyndon A. … Improving employee voice about transgressive or disruptive behavior: a case study. … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

258. To Resuscitate or Not? | PSNet
     psnet.ahrq.gov/web-mm/resuscitate-or-not
     November 01, 2011 - An ethical analysis suggests that the admonition to ′do no harm′ does not override an autonomous patient … experience potentially life-threatening errors in their care.( 5,6 ) Patients can be asked directly how … Do house officers learn from their mistakes? JAMA. 1991;265:2089-94.[ go to PubMed ] 3. … Would physicians override a do-not-resuscitate order when a cardiac arrest is iatrogenic? … December 3, 2014 How will we know patients are safer?

259. In Conversation With… Jack Needleman, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
     September 01, 2012 - The staff nurse that comes onto a med–surg unit has 4 to 8 patients assigned, each of whom has a to-do … list at the start of the shift, and has to figure out how to integrate those to-do lists, how to keep … Think about your to-do list as a stack of things to get done. … We need to do those simultaneously. … That's not a productive way to do it.

260. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? | PSNet
     psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
     June 24, 2020 - very few nurses come to work to do a bad job. … Do three things to determine why it made sense for the nurse to do what he or she did. … How many other patients were there at the time; how long had the nurse been on shift? … How do hospitals manage these kinds of errors in general? Not very impressively. … This, in the end, is how a hospital can balance accountability and learning.