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

301. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49531/psn-pdf
     March 01, 2007 - Retrieving medications is something nurses do many times during a shift, and, most of the time, it goes … participated in a frank discussion about what had happened and how future mistakes of this type could … of no-harm or "near miss" errors is even greater.(15) How to improve reporting has become a much-researched … management would take no notice and was not likely to do anything about the problem); acceptance of … Committed to Safety: Ten Case Studies on Reducing Harm to Patients.

302. In Conversation with...James L. Reinertsen, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
     August 01, 2007 - RW: If the CEO has a hard time figuring out how much to bite off when he or she is trying to change … to do. … getting better, and how do we compare to the theoretical ideal? … There's a third question that boards are very interested in—how do we compare to others? … The case study experience out of things like the Pursuing Perfection program offers examples like the

303. Hospital safety climate and safety outcomes: is there a relationship in the VA? | PSNet
     psnet.ahrq.gov/issue/hospital-safety-climate-and-safety-outcomes-there-relationship-va
     October 14, 2009 - a few of the PSIs. … Department of Veterans Affairs case study. … June 16, 2011 How does patient safety culture in the operating room and post-anesthesia … care unit compare to the rest of the hospital? … Resources Validating the Patient Safety Indicators in the Veterans Health Administration: do

304. A piece of my mind. Mentorship malpractice. | PSNet
     psnet.ahrq.gov/issue/piece-my-mind-mentorship-malpractice
     September 16, 2020 - dysfunctional mentorship behaviors that can affect success in academic medicine, this editorial explains how … RIS Download Citation Related Resources From the Same Author(s) How … October 13, 2018 Mind the overlap: how system problems contribute to cognitive failure … August 14, 2019 Do clinicians know which of their patients have central venous catheters … April 16, 2018 How to prevent burnout (maybe).

305. Errors associated with outpatient computerized prescribing systems. | PSNet
     psnet.ahrq.gov/issue/errors-associated-outpatient-computerized-prescribing-systems
     June 28, 2010 - Careful attention is required to assure safe processes and functionality . … RIS Download Citation Related Resources From the Same Author(s) How … January 9, 2008 Overcoming barriers to the implementation of a pharmacy bar code scanning … system for medication dispensing: a case study. … January 7, 2015 How do community pharmacies recover from e-prescription errors?

306. A Loss of Trust and a Missed Diagnosis | PSNet
     psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
     October 31, 2023 - guide front-line providers on how to use these medications safely. … Systematic Approach to Improving Patient Safety Diagnosis This case demonstrates how a delay in diagnosis … So how do primary care physicians, who are tasked with managing multiple chronic diseases and health … Even within a primary care practice, it may be helpful to involve a colleague to look at a case with … to Change It and How It Changes Safety March 1, 2017 Incident reporting in

307. Diagnosing Diagnostic Mistakes | PSNet
     psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
     April 30, 2014 - on evaluating diagnostic decisions to determine how many truly represent “errors.” … It is not clear how many observers, blinded to the outcome, would miss this finding, but surely some … have suffered from AD.( 10-12 ) Certainly those reports do not include patients requiring a magnified … In addition, they do not intend to include information or discuss investigational or off-label use of … Three case reports. Eff Clin Pract. 2002;5:23-28. [ go to PubMed ] 9. Berlin L.

308. Preparing for Health Reform: The Federal Government and the Nursing Workforce | PSNet
     psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
     September 01, 2012 - Little research has examined how to get maximum value out of the nurses or how to allow them to shed … 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. … That's not a productive way to do it.

309. Communicating with patients about medical errors: a review of the literature. | PSNet
     psnet.ahrq.gov/issue/communicating-patients-about-medical-errors-review-literature
     December 23, 2008 - , that patients and the general public favor disclosure, and that physicians do in fact support the practice … However, little practical guidance exists as to the nuts and bolts of who, what, when, and how to disclose … , which the authors point out must become a focus of future efforts. … December 22, 2018 Disclosure of medical errors: what factors influence how patients respond … October 26, 2010 Narrative review: do state laws make it easier to say "I'm sorry"?

310. The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units. | PSNet
     psnet.ahrq.gov/issue/impact-safety-organizing-trusted-leadership-and-care-pathways-reported-medication-errors
     January 18, 2011 - Case studies of high-reliability organizations reinforce the importance of maintaining an organizational … commitment and a culture of safety . … on a given unit. … September 29, 2017 (How) do we learn from errors? … February 27, 2014 Implementing a systematic response to medication errors.

311. Eliciting willingness-to-pay to prevent hospital medication administration errors in the UK: a contingent valuation survey. | PSNet
     psnet.ahrq.gov/issue/eliciting-willingness-pay-prevent-hospital-medication-administration-errors-uk-contingent
     March 28, 2012 - Eliciting willingness-to-pay to prevent hospital medication administration errors in the UK: a contingent … Eliciting willingness-to-pay to prevent hospital medication administration errors in the UK: a contingent … September 23, 2020 Checklists to reduce diagnostic error: a systematic review of the … June 1, 2022 How do patients respond to safety problems in ambulatory care? … April 7, 2021 - April 7, 2021 Why do healthcare professionals fail to escalate as

312. Managing competing organizational priorities in clinical handover across organizational boundaries. | PSNet
     psnet.ahrq.gov/issue/managing-competing-organizational-priorities-clinical-handover-across-organizational
     February 07, 2024 - Analysis of 270 handoffs between ambulances to emergency departments (EDs) and EDs to inpatient units … uncovered many tensions and themes, such as how competing patient flow priorities can impact the quality … Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case … studies. … July 10, 2013 Improving teamwork on general medical units: when teams do not work face-to-face

313. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.131_slideshow.ppt
     August 01, 2006 - A 57-year-old male with T8 paraplegia from a remote gunshot wound, hypertension, and diastolic dysfunction … Use your five senses….Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice … physician might be reluctant to make a clinical diagnosis that could be readily made at the bedside … How Are Our Physical Exam Skills? … cmd=retrieve&db=pubmed&dopt=abstract&list_uids=2316561 Why Do We Order So Many Tests?

314. Incidence, preventability and consequences of adverse events in older people: results of a retrospective case-note review. | PSNet
     psnet.ahrq.gov/issue/incidence-preventability-and-consequences-adverse-events-older-people-results-retrospective
     March 03, 2011 - Citation Text: Sari ABA, Cracknell A, Sheldon T. … to enhance safety: a systematic review. … September 15, 2010 Implementation of a parent-centered approach to the preinduction checklist … June 3, 2020 View More Related Resources How do hospital inpatients … and adverse events in older patients admitted to hospital: a retrospective cohort study.

315. Detecting medication order discrepancies in nursing homes: how RNs and LPNs differ. | PSNet
     psnet.ahrq.gov/issue/detecting-medication-order-discrepancies-nursing-homes-how-rns-and-lpns-differ
     August 15, 2013 - Study Detecting medication order discrepancies in nursing homes: how RNs and LPNs … Detecting medication order discrepancies in nursing homes: how RNs and LPNs differ. … Detecting medication order discrepancies in nursing homes: how RNs and LPNs differ. … January 8, 2020 Do leadership style, unit climate, and safety climate contribute to safe … November 6, 2015 In-home medication reviews: a novel approach to improving patient care

316. How can we keep patients with dementia safe in our acute hospitals? A review of challenges and solutions. | PSNet
     psnet.ahrq.gov/issue/how-can-we-keep-patients-dementia-safe-our-acute-hospitals-review-challenges-and-solutions
     February 04, 2015 - How can we keep patients with dementia safe in our acute hospitals? … This review examines risks related to caring for patients with dementia in a hospital setting and includes … a seven-factor approach to improve safety. … How can we keep patients with dementia safe in our acute hospitals? … January 30, 2019 How do hospital inpatients conceptualise patient safety?

317. CVC Placement: Speak Now or Do Not Use the Line | PSNet
     psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
     November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. … established similar procedure services for direct patient care and/or for training purposes, although how … How many attempts were made before achieving access? … If clinicians have any doubt along the way, it is incumbent on them to "speak now or do not use the line … [go to PubMed] 14. Lenhard A, Moallem M, Marrie RA, Becker J, Garland A.

318. Safety in Numbers: Evidence-based Development of a Medicine Management Learning Tool. | PSNet
     psnet.ahrq.gov/issue/safety-numbers-evidence-based-development-medicine-management-learning-tool
     June 30, 2013 - Articles in this special issue outline the development and outcomes of a 20-year initiative to improve … September 6, 2017 A medication safety education program to reduce the risk of harm caused … January 15, 2014 Nursing student medication errors: a case study using root cause analysis … May 1, 2013 The novice nurse and clinical decision-making: how to avoid errors. … May 11, 2011 Do calculation errors by nurses cause medication errors in clinical practice

319. In Conversation With… Matthew Weinger, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
     August 01, 2018 - developed technologically where it wasn't a huge ordeal to do one study. … RW : In a field like nuclear power or aviation, how do you know when you're doing too much? … How do you calibrate that? … how that's going to play out. … malpractice studies and other case reports, such as failure to escalate therapy when the initial therapy

320. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. | PSNet
     psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
     February 21, 2020 - As a backup, most EHRs have a system of sending alerts directly to providers to notify them of new results … Unfortunately, these alerts do not always have the intended effect: one study in a primary care setting … diagnostic error found multiple studies detailing how poorly maintained problem lists or copy-pasted … medical conditions, in combination with standardized handoffs and discharge summaries that prioritize to-do … August 31, 2022 How to "DEAL" with disruptive physician behavior.