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

461. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet) | PSNet
     psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
     April 01, 2005 - How do you prospectively think that through? What was their charge? … For example, we noticed that sleep-deprived interns would often fail to do a very thorough history and … CL: Well, I personally don't think that a shift-work mentality has much to do with the number of hours … I think it has to do with a professional sense of when it would be an appropriate time to walk out the … How did your study compare to those?

462. The Media’s Role in Patient Safety | PSNet
     psnet.ahrq.gov/perspective/medias-role-patient-safety
     April 27, 2022 - material and to do so with less space and/or in a smaller amount of time. … Improving Diagnosis in Health Care , 8  where they included case studies, but the names were semi-shrouded … , without last name (though you could easily find them via an internet search), and the full case studies … So, use it not to get the story into the mainstream, but as a tool, similar to how web data can be used … they need to do just that.

463. A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths. | PSNet
     psnet.ahrq.gov/issue/comprehensive-overview-medical-error-hospitals-using-incident-reporting-systems-patient
     October 16, 2013 - unable to provide a comprehensive picture of patient safety. … Related Resources From the Same Author(s) Informal learning from error in hospitals: what do … we learn, how do we learn and how can informal learning be enhanced? … May 1, 2019 A review of educational strategies to improve nurses' roles in recognizing … and responding to deteriorating patients.

464. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49747/psn-pdf
     December 01, 2015 - 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

465. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49415/psn-pdf
     September 01, 2003 - the importance of and barriers to effective interpersonal communication To appreciate how to design … (eg, "Get an IV in this guy") without any direction as to who should do it. … In the complex care environment, one also needs to know when and how to apply knowledge, solve problems … to do something incorrectly. … (or not do) in different clinical situations.

466. In Conversation With... Charles A Crecelius, MD, PhD, CMD and Lori L Popejoy, PhD, RN, FAAN | PSNet
     psnet.ahrq.gov/perspective/conversation-charles-crecelius-md-phd-cmd-and-lori-l-popejoy-phd-rn-faan
     October 28, 2020 - Do you want to start talking about how the COVID-19 response and the work of the Initiative have intersected … The concept of social distancing is pretty foreign to staff and many don’t know how to safely have a … do that job in a pandemic. … How do you separate people from each other if one becomes ill and the other does not? … You can have huge teleconference calls where people can hear case studies, hear the expertise, and ask

467. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33782/psn-pdf
     March 01, 2015 - Ratios greater than 1 (or 100 depending on how the ratio is reported) are seen to suggest unsafe care … (most unsafe practices do not cause death) and low specificity (most deaths do not reflect unsafe care … [go to PubMed] 9. Mohammed MA, Deeks JJ, Girling A, et al. … How Safe is Your Hospital? Dr Foster Unit. London, UK: Imperial College London; 2009. … Is it a predictor of quality? N Engl J Med. 1987;317:1674-1680. [go to PubMed] 16.

468. The effect of an electronic SBAR communication tool on documentation of acute events in the pediatric intensive care unit. | PSNet
     psnet.ahrq.gov/issue/effect-electronic-sbar-communication-tool-documentation-acute-events-pediatric-intensive-care
     August 12, 2015 - EndNote 7 XML Endnote tagged PubMedId RIS Download Citation Save Save to … RIS Download Citation Related Resources From the Same Author(s) How … well do health professionals interpret diagnostic information? … identify and mitigate adverse safety events: a case study with unplanned extubations. … April 27, 2019 Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician

469. Operationalizing Patient Safety at Academic Medical Centers | PSNet
     psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
     August 01, 2010 - Enhancing the informal curriculum of a medical school: a case study in organizational culture change. … How is a catheter placed right now, and then how is it maintained and manipulated? … at the point of care as they do their work and try to figure out how to free people's time to do that … So a lot of doubters say, "How do you really know that the innovations we put in place are responsible … I mean, how often when a patient is scheduled to be in a cath lab at 10:00 AM does it actually happen

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49639/psn-pdf
     November 01, 2011 - The pharmacist came to the ED to teach the patient how to do the subcutaneous LMWH injections, which … Near misses are unsafe acts that have the potential to injure a patient, but do not. … capture errors and their consequences, it is not certain how common near misses are relative to errors … How should this case be handled in an ideal world? … They are free lessons about how things go wrong and how they can be fixed before someone gets hurt.

471. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49483/psn-pdf
     June 01, 2005 - A creatine kinase (CK) peaked to 7236 U/L, CKMB to 37 U/L. … How would you do it? What would you be likely to find? What solutions could be implemented? … We do have a small amount of additional information from this event available to us to review. … the scope of this commentary but has been reviewed in a past WebM&M case.(11) Although we do not know … Do house officers learn from their mistakes? JAMA. 1991;265:2089-2094. [ go to PubMed ] 18.

472. Diuretics and Electrolyte Abnormalities | PSNet
     psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
     February 15, 2017 - State how commonly used thiazide diuretics can contribute to hyponatremia. … The Commentary by Tobias Dreischulte, MPharm, MSc, PhD This case illustrates how a commonly used … patients do not develop hyponatremia. … [go to PubMed] 3. Clayton JA, Rodgers S, Blakey J, Avery A, Hall IP. … August 12, 2020 How is physicians' implicit prejudice against the obese and mentally

473. Diagnostic Overshadowing Dangers | PSNet
     psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
     February 12, 2020 - At the time of discharge, it was unclear how much of her cardiac function might recover. … biases that negatively impact care, especially when they seek acute health care from providers who do … ( 4 ), emergency providers receive little instruction during their training regarding how to best and … talk to the patient directly or to reach out to a patient's family or outside providers. … [go to PubMed] 8. Singhal A, Tien YY, Hsia RY.

474. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49762/psn-pdf
     June 01, 2016 - This case provides an opportunity to discuss how to optimally transmit wishes for life-sustaining treatments … the data-sharing agreements that first must be forged to do so safely. … State registries do not cross state lines, while patients often do. … health care preferences and how to ensure those wishes can easily be transmitted across health care … Ideally, the original hospital team would have been aware of how to upload his POLST, and this would

475. Accreditation and Regulation: Can They Help Improve Patient Safety? | PSNet
     psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
     April 01, 2009 - Stories from the sharp end: case studies in safety improvement. Milbank Q. 2006;84:165-200. … How do you come down on that philosophical divide? … How you choose to do that—you have a lot of leeway. … How do you respond to that? … We continuously reach out to all of our customers and other stakeholders to understand how we can do

476. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33785/psn-pdf
     May 01, 2015 - how surgeons do different types of procedures but how well they do them. … programs do things and how surgeons operate. … The problem was that we needed to do it on a larger scale, and we needed to do it in a way that allowed … It is intended to basically coach every bariatric surgeon in the state of Michigan on how to do better … What should a patient do today?

477. Dual process models of clinical reasoning: the central role of knowledge in diagnostic expertise. | PSNet
     psnet.ahrq.gov/issue/dual-process-models-clinical-reasoning-central-role-knowledge-diagnostic-expertise
     March 08, 2017 - A vignette study to assess recognition of cognitive biases in clinical case workups. … April 12, 2019 Disrupting diagnostic reasoning: do interruptions, instructions, and experience … February 6, 2014 View More Related Resources How America’s health … September 18, 2024 Diagnostic Stewardship as a Model to Improve the Quality and Safety … July 17, 2024 "What do health inequities have to do with anything?".

478. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49792/psn-pdf
     May 01, 2017 - do more with fewer resources, while maintaining timeliness and decreasing costs, increases the opportunity … presentations like this in a timely fashion.(22,23) So how can ED providers handle this area of vulnerability … the ED that led to a hospitalization could be a useful way to look for these missed opportunities. … This case highlights how a focus on basic clinical skills, cognitive processes, and team-based care … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

479. The relationship between physician practice characteristics and physician adoption of electronic health records. | PSNet
     psnet.ahrq.gov/issue/relationship-between-physician-practice-characteristics-and-physician-adoption-electronic
     November 13, 2013 - July 14, 2010 New technology, new errors: how to prime an upgrade of an insulin infusion … case study. … November 16, 2022 CancelRx: a health IT tool to reduce medication discrepancies in the … A study of facilitators and barriers to physicians' use of electronic health records. … 21, 2011 Notification of abnormal lab test results in an electronic medical record: do

480. Standards, audits, and saying I'm sorry: an engineer's family proposes solutions. | PSNet
     psnet.ahrq.gov/issue/standards-audits-and-saying-im-sorry-engineers-family-proposes-solutions
     February 22, 2010 - February 22, 2010 How will state medical boards handle cases involving disclosure and … April 27, 2022 Committed to Safety: Ten Case Studies on Reducing Harm to Patients. … October 7, 2008 Stories from the sharp end: case studies in safety improvement. … May 22, 2019 When a nurse is prosecuted for a fatal medical mistake, does it make medicine … July 31, 2012 Narrative review: do state laws make it easier to say "I'm sorry"?