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Total Results: 2,386 records

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

321. DNR in the OR and Afterwards | PSNet
     psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
     July 01, 2003 - The Commentary When a patient with a “do not resuscitate” (DNR) order undergoes surgery or conscious … Why did this failure occur, and how might it be prevented? … How can physicians be reminded to address DNR orders in the perioperative period? … [go to PubMed] 5. Guarisco KK. Managing do-not-resuscitate orders in the perianesthesia period. … room or how care might be limited.”

322. Level IV evidence—adverse anecdote and clinical practice. | PSNet
     psnet.ahrq.gov/issue/level-iv-evidence-adverse-anecdote-and-clinical-practice
     October 06, 2021 - This perspective describes how stories can help encourage commitment to safety in residents. … February 15, 2023 Implementation of a discharge education program to improve transitions … July 21, 2021 Why do hundreds of US women die annually in childbirth? … March 8, 2019 What we can do about maternal mortality—and how to do it quickly. … October 10, 2012 A system-wide initiative to prevent retained vaginal sponges.

323. A Real Heartache | PSNet
     psnet.ahrq.gov/web-mm/real-heartache
     October 01, 2018 - It's also a helpful reminder about how retrospective case reviews can capture not only individual provider … diagnosis of a non-cardiac etiology, the addition of a positive response to an antacid served to confirm … Changes in the numeric descriptive scale for pain after sublingual nitroglycerin do not predict cardiac … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not … positive-exemplar case study of a new patient safety tool.

324. One Toxic Drug Is Not Like Another | PSNet
     psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
     October 02, 2019 - If the answer to the latter question is yes, then, "What gaps do I currently have that I will need to … How will I know if the treatment I am providing is effective and safe?" … help physicians discover gaps in competencies and then provide guidance on how to best address and close … The Culture Code: An Ingenious Way to Understand Why People Around the World Live and Buy as They Do. … November 28, 2012 How teams work—or don’t—in primary care: a field study on internal

325. Medical error, incident investigation and the second victim: doing better but feeling worse? | PSNet
     psnet.ahrq.gov/issue/medical-error-incident-investigation-and-second-victim-doing-better-feeling-worse
     July 29, 2020 - randomized trial of a multifactorial strategy to prevent serious fall injuries. … December 3, 2014 Case studies of patient safety research classics to build research capacity … January 19, 2014 How will we know patients are safer? … June 23, 2021 Five strategies for how patients and families can improve patient safety … September 5, 2018 Do hospitals support second victims?

326. Physical Diagnosis: A Lost Art? | PSNet
     psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
     January 17, 2018 - The result is that we see few people percuss the chest, and fewer still do it with any confidence or … What is most gratifying is how quickly these young physicians pick up and see both the utility of the … bedside examination and its limitations in a resource poor setting and how they come to see how valuable … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not … February 28, 2011 WebM&M Cases Do Not Disturb!

327. In Conversation with…Gerald B. Hickson, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
     December 01, 2009 - RW: How do you do this across disciplines? … RW: How do apologies and disclosure fit into all of this? … The goal is to have a better understanding of how and why people react the way they do and, through this … resulting in either termination of employment or suspension of staff privileges (see Case Study ). … Case Study Back to Top (Go to case study citation in perspective) One organization was having a

328. Taking patients' narratives about clinicians from anecdote to science. | PSNet
     psnet.ahrq.gov/issue/taking-patients-narratives-about-clinicians-anecdote-science
     March 20, 2019 - This commentary explores how patient narratives can be used to assess care quality and suggests that … September 23, 2020 When mistakes multiply: how inadequate responses to medical mishaps … April 24, 2018 A method to identify pediatric high-risk diagnoses missed in the emergency … November 16, 2022 A national implementation project to prevent catheter-associated urinary … September 29, 2017 Why do people stop taking their meds?

329. Raising an alarm, doctors fight to yank hospital ICUs into the modern era. | PSNet
     psnet.ahrq.gov/issue/raising-alarm-doctors-fight-yank-hospital-icus-modern-era
     February 14, 2024 - February 14, 2024 Dermatology faces a reckoning: lack of darker skin in textbooks and … November 9, 2016 Emergency lights and sirens on ambulances may do more harm than good … October 19, 2016 View More Related Resources How redesigning the … improve alarm fatigue in an intensive care unit: a pilot project. … March 1, 2011 Intensive care unit alarms—how many do we need?

330. Root Cause Analysis Gone Wrong | PSNet
     psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
     August 28, 2024 - understand what happened and why and to identify how to prevent future incidents. … Organizational Accident Causation Model ( Figure ).( 12 ) Such frameworks facilitate consideration of how … Its purpose should remain relentlessly focused on how to make improvements, and how to make them in the … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not … A multisite case study.

331. Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study. | PSNet
     psnet.ahrq.gov/issue/patient-safety-intensive-care-results-multinational-sentinel-events-evaluation-see-study
     March 03, 2011 - December 22, 2018 Case studies of patient safety research classics to build research … (PMOS): a validation study. … to improve clinical handovers. … April 17, 2013 Adverse drug events in a paediatric intensive care unit: a prospective … July 22, 2010 Intensive care unit alarms—how many do we need?

332. Clinical Risk Management. Enhancing Patient Safety. 2nd ed. | PSNet
     psnet.ahrq.gov/issue/clinical-risk-management-enhancing-patient-safety-2nd-ed
     May 20, 2019 - seeking improvements through a safety lens. … April 5, 2023 How to do no harm: empowering local leaders to make care safer in low-resource … Public Protection Posed by a Doctor as a Result of Concerns about their Practice during the Pandemic … the Breadth and Depth of Relationships through National Quantitative Surveys and In-depth Qualitative Case … Studies.

333. The Empty Bag | PSNet
     psnet.ahrq.gov/web-mm/empty-bag
     June 01, 2018 - Sometimes it is necessary to look beyond the people and ask how the right equipment might reduce the … [go to PubMed] 6. Gawande A. The Checklist Manifesto: How to Get Things Right. … It is imperative to figure out how to develop design safety features that make it easy for the user to … do the right thing. … Alarms are difficult to prioritize. It is unclear how to resolve alarm issues. 13.

334. The problem with preventable deaths. | PSNet
     psnet.ahrq.gov/issue/problem-preventable-deaths
     July 24, 2024 - digital era: a scoping literature review. … May 18, 2022 Approaches to improving patient safety in integrated care: a scoping review … December 21, 2016 "What's psychology got to do with it?" … June 21, 2015 Challenges and opportunities to prevent transfusion errors: a Qualitative … September 20, 2012 Surgical 'never events': how common are adverse occurrences?

335. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33672/psn-pdf
     September 01, 2008 - research standpoint, there is still not a lot of information out there to show how effective this technology … We do have fairly good evidence in terms of how well barcode technology can reduce the incidence of … possible to do that. … the best that we'll be able to do? … to do the scanning?

336. Picking Up the Cause of the Stroke | PSNet
     psnet.ahrq.gov/web-mm/picking-cause-stroke
     August 07, 2024 - ), it does highlight how PICCs are far from benign. … How best to use PICCs is an important clinical and safety question. … Do clinicians know which of their patients have central venous catheters? … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not … October 11, 2023 How physicians think: a case-based diagnostic simulation exercise.

337. Harm From Alarm Fatigue | PSNet
     psnet.ahrq.gov/web-mm/harm-alarm-fatigue
     February 14, 2018 - What types and numbers of alarms occur with hospital monitor devices and how accurate are they? … the atrial fibrillation, the monitor could generate a prompt, "do you want to continue to hear an atrial … audible alarms that do not warrant treatment can be changed to inaudible text message alerts. … Clinicians should learn how to tailor alarm thresholds to an individual patient to avoid an excessive … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

338. Security Lapse | PSNet
     psnet.ahrq.gov/web-mm/security-lapse
     December 18, 2019 - 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 negotiate

339. Patient Mix-Up | PSNet
     psnet.ahrq.gov/web-mm/patient-mix
     December 01, 2007 - He was scheduled to receive a dose of IV haloperidol at 7AM. … for about 15% of all inpatients at UCSF) to see how often there were identical last names over a three-month … 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

340. In Conversation With… Michelle Mello, MPhil, JD, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
     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