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

81. Do house officers learn from their mistakes? | PSNet
    psnet.ahrq.gov/issue/do-house-officers-learn-their-mistakes
    April 19, 2011 - Their survey revealed a surprisingly high rate of acknowledged serious errors, many contributing to patient … RIS Download Citation Related Resources From the Same Author(s) How … June 22, 2009 A randomized trial of a multifactorial strategy to prevent serious fall … prospective observational case study of five teaching hospitals. … September 28, 2016 Beyond "see one, do one, teach one": toward a different training paradigm

82. Getting Into Patient Safety: A Personal Story | PSNet
    psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
    August 01, 2006 - , stating not just how many days since a worker had lost a day, but also how many days it has been since … In all honesty, I really didn't have a whole lot else to do. … number of very energetic, creative people involved in trying to figure out how we do all this. … The response of our hospitals was not at all one of resistance; it was "How do we do it?" … positive-exemplar case study of a new patient safety tool.

83. Organizational ambidexterity and the hybrid middle manager: the case of patient safety in UK hospitals. | PSNet
    psnet.ahrq.gov/issue/organizational-ambidexterity-and-hybrid-middle-manager-case-patient-safety-uk-hospitals
    January 29, 2014 - EndNote 7 XML Endnote tagged PubMedId RIS Download Citation Save Save to … professional, and a broad view of responsibilities was associated with a stronger focus on patient safety … March 22, 2023 Disrupting diagnostic reasoning: do interruptions, instructions, and experience … June 21, 2016 Exploring the role of communications in quality improvement: a case study … November 16, 2011 One-stop diagnostic breast clinics: how often are breast cancers missed

84. Harmful errors: how will your facility respond? | PSNet
    psnet.ahrq.gov/issue/harmful-errors-how-will-your-facility-respond
    November 05, 2014 - Newspaper/Magazine Article Harmful errors: how will your facility respond? … Citation Text: Harmful errors: how will your facility respond? ISMP Medication Safety Alert! … response to codes. … case study. … March 8, 2015 Learning from mistakes in New Zealand hospitals: what else do we need besides

85. How effective are incident-reporting systems for improving patient safety? A systematic literature review. | PSNet
    psnet.ahrq.gov/issue/how-effective-are-incident-reporting-systems-improving-patient-safety-systematic-literature
    January 18, 2023 - January 18, 2023 Stories from the sharp end: case studies in safety improvement. … February 24, 2021 A system-based approach to managing patient safety in ambulatory care … January 10, 2018 Do HSMRs really measure patient safety?  … November 13, 2019 Healthcare scandals and the failings of doctors: do official inquiries … November 6, 2015 Freedom to Speak Up: A Review of Whistleblowing in the NHS.

86. Feasibility of prospective error reporting in home palliative care: a mixed methods study. | PSNet
    psnet.ahrq.gov/issue/feasibility-prospective-error-reporting-home-palliative-care-mixed-methods-study
    November 11, 2020 - EndNote 7 XML Endnote tagged PubMedId RIS Download Citation Save Save to … PubMed citation Free full text Save Save to your library Print Download PDF … prospective observational case study of five teaching hospitals. … August 27, 2009 Early experience of peer advocate program: using quality improvement to … October 11, 2023 How safe do dying people feel at home?

87. Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation. | PSNet
    psnet.ahrq.gov/issue/why-do-healthcare-professionals-fail-escalate-early-warning-system-ews-protocol-qualitative
    August 25, 2021 - Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? … March 24, 2021 A qualitative study of what care workers do to provide patient safety … July 7, 2021 What do patients and their carers do to support the safety of cancer treatment … March 21, 2012 Understanding how rapid response systems may improve safety for the acutely … September 24, 2010 Committed to Safety: Ten Case Studies on Reducing Harm to Patients

88. Failure to Report | PSNet
    psnet.ahrq.gov/web-mm/failure-report
    July 01, 2008 - 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 … question in recent years, with the reasons for nonreporting found to be many and varied.( 16 ) How … Committed to Safety: Ten Case Studies on Reducing Harm to Patients.

89. In Conversation With... Cindy Brach | PSNet
    psnet.ahrq.gov/perspective/conversation-cindy-brach
    December 27, 2019 - KH : Do you think you have to understand a culture specifically to deliver culturally competent care? … The approach that the toolkit took was to create a separate tool called “ How to deliver the re-engineered … The module includes train-the-trainer resources and instructional guides that include short case studies … Accessed December 5, 2019. [25] TeamSTEPPS Case Studies. ahrq.gov. … https://www.ahrq.gov/teamstepps/case-studies/index.html .

90. Tacit Handover, Overt Mishap | PSNet
    psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
    August 01, 2006 - Confident that she knew how to manage these devices, she approached the head anesthesiologist for the … or what's going on currently that might impact what I do or how I do it?" … And providers will be trained to do it, perhaps best via simulation.( 9,10 ) The data elements of a … As cases like this one teach us, to do less no longer makes sense. … positive-exemplar case study of a new patient safety tool.

91. Cultural Competence and Patient Safety | PSNet
    psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
    December 27, 2019 - The module includes train-the-trainer resources and instructional guides that include short case studies … Accessed December 5, 2019. [25] TeamSTEPPS Case Studies. ahrq.gov. … https://www.ahrq.gov/teamstepps/case-studies/index.html . … KH : Do you think you have to understand a culture specifically to deliver culturally competent care? … The approach that the toolkit took was to create a separate tool called “ How to deliver the re-engineered

92. How many die from medical mistakes in US hospitals? | PSNet
    psnet.ahrq.gov/issue/how-many-die-medical-mistakes-us-hospitals
    January 23, 2013 - Citation Text: How many die from medical mistakes in US hospitals? Allen M. … January 23, 2013 How hepatitis probe led to clinic: old-fashioned legwork yielded clues … March 21, 2011 First do no harm. … January 22, 2014 Do no harm: hospital care in Las Vegas. … December 4, 2016 To make hospitals less deadly, a dose of data.

93. Does a unit shift report "blackout" period improve patient safety? | PSNet
    psnet.ahrq.gov/issue/does-unit-shift-report-blackout-period-improve-patient-safety
    August 04, 2021 - This commentary summarizes how one hospital sought to to avoid miscommunications and disruptions by … as a patient safety strategy. … to preventing the harm associated with ambulance handover delays. … March 19, 2019 Interruptions in a level one trauma center: a case study. … July 28, 2010 Do not put medication safety "on hold" with boarded patients.

94. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.242_slideshow.ppt
    June 01, 2011 - : State how frequently physicians care for family or relatives Describe the risks associated with caring … I think the clerk recognized me as a physician on staff and handed it to me. … or substance abuse May try to spare a relative from a painful procedure Can become too involved in … a case and unable to step back when necessary See Notes for reference … What do you do when your loved one is ill? The line between physician and family member.

95. Cognitive biases encountered by physicians in the emergency room. | PSNet
    psnet.ahrq.gov/issue/cognitive-biases-encountered-physicians-emergency-room
    June 19, 2024 - reports of diagnostic errors. … June 19, 2024 Diagnostic errors in uncommon conditions: a systematic review of case reports … March 23, 2022 EMS non-conveyance: a safe practice to decrease ED crowding or a threat … April 27, 2022 What do emergency department physicians and nurses feel? … April 8, 2018 Autopsy interrogation of emergency medicine dispute cases: how often are

96. The COVID trap: pediatric diagnostic errors in a pandemic world. | PSNet
    psnet.ahrq.gov/issue/covid-trap-pediatric-diagnostic-errors-pandemic-world
    October 20, 2021 - Using case studies, this commentary describes how availability bias, diagnostic momentum, and premature … September 14, 2022 A diagnostic time-out to improve differential diagnosis in pediatric … August 19, 2020 Handshake antimicrobial stewardship as a model to recognize and prevent … August 12, 2020 Do no harm: reaffirming the value of evidence and equipoise while minimizing … July 8, 2020 COVID-19 — a reminder to reason May 20, 2020 View More

97. Discussing the undiscussable with the powerful: why and how faculty must learn to counteract organizational silence. | PSNet
    psnet.ahrq.gov/issue/discussing-undiscussable-powerful-why-and-how-faculty-must-learn-counteract-organizational
    November 16, 2022 - Discussing the undiscussable with the powerful: why and how faculty must learn to counteract organizational … Discussing the undiscussable with the powerful: why and how faculty must learn to counteract organizational … A multisite case study. … December 18, 2017 Using a potentially aggressive/violent patient huddle to improve health … February 12, 2014 WebM&M Cases Do Not Disturb!

98. The Case for Patient Flow Management | PSNet
    psnet.ahrq.gov/web-mm/case-patient-flow-management
    February 23, 2019 - The patient did not call to schedule an appointment and was not prompted to do so. … Our commentary will focus on a different issue—how scheduling systems and processes can impede access … Weber DO. … Queue Fever, Parts 1 and 2: A little number crunching can show hospitals how many beds and staff members … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

99. Near Miss with Bedside Medications | PSNet
    psnet.ahrq.gov/web-mm/near-miss-bedside-medications
    February 01, 2006 - 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 … They are free lessons about how things go wrong and how they can be fixed before someone gets hurt. … December 3, 2014 Case studies of patient safety research classics to build research capacity

100. Recruitment of hospitals for a safety climate study: facilitators and barriers. | PSNet
     psnet.ahrq.gov/issue/recruitment-hospitals-safety-climate-study-facilitators-and-barriers
     June 16, 2011 - participate in the survey, and how recruitment difficulties could have biased the study results.  … Despite efforts to avoid selection bias in recruiting hospitals, hospitals that participated tended to … Department of Veterans Affairs case study. … April 11, 2011 How do black-serving hospitals perform on patient safety indicators? … October 13, 2010 Empowered to improve.