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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.
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psnet.ahrq.gov/issue/do-no-harm-hospital-care-las-vegas
October 02, 2013 - Citation Text:
Do no harm: hospital care in Las Vegas. Allen M; Richards A. … Allen M; Richards A. … Copy Citation
Related Resources From the Same Author(s)
How many die from … January 23, 2013
How hepatitis probe led to clinic: old-fashioned legwork yielded clues … March 21, 2011
First do no harm.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
June 01, 2005 - analysis
Case: Getting to the Root of the Matter
A 65-year-old man with atrial fibrillation, … Performing Root Cause Analysis
How would you do it? … Medication reconciliation: a practical tool to reduce the risk of medication errors. … Do house officers learn from their mistakes? JAMA. 1991;265:2089-2094. … Do house officers learn from their mistakes? JAMA. 1991;265:2089-2094.
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psnet.ahrq.gov/issue/graduate-medical-education-and-patient-safety-busy-and-occasionally-hazardous-intersection
March 02, 2011 - This case study presents the events surrounding the death of a woman admitted to an academic medical … February 3, 2011
Work hour rules and contributors to patient care mistakes: a focus group … July 2, 2008
How do hospitalized patients feel about resident work hours, fatigue, and … November 16, 2011
A program to prevent catheter-associated urinary tract infection in … March 4, 2019
Leveraging the continuum: a novel approach to meeting quality improvement
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
December 01, 2004 - For example, if a hospitalist fails to arrange appropriate follow-up for a patient with a solitary pulmonary … What the Patient Can do to Improve Safety at Discharge
Understand important new health problems and … events
Arrange home nursing visits
What the System can do to Improve Safety at Discharge
In-hospital … Do you know which of your home medications to continue, what the current doses are, and which you should … do if things are not going well
Confirm that patient comprehends your instructions
Include a family
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psnet.ahrq.gov/issue/evaluation-measurement-system-assess-icu-team-performance
November 17, 2014 - Evaluation of a Measurement System to Assess ICU Team Performance. … Evaluation of a Measurement System to Assess ICU Team Performance. … November 17, 2014
A systematic review of teamwork in the intensive care unit: what do … February 8, 2017
Unreported errors in the intensive care unit: a case study of the way … December 22, 2010
How RNs rescue patients: a qualitative study of RNs' perceived involvement
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psnet.ahrq.gov/issue/first-do-no-harm-lost-concept-medical-education
December 01, 2004 - Commentary
Is "first do no harm" a lost concept in medical education? … Is "first do no harm" a lost concept in medical education. MedGenMed. 2006;8(3):77. … to improve teamwork and quality for hospitalized patients: a multi-site qualitative comparative case … study. … December 16, 2009
Reflection and analysis of how pharmacy students learn to communicate
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psnet.ahrq.gov/issue/how-will-we-know-patients-are-safer-organization-wide-approach-measuring-and-improving-safety
May 20, 2009 - The authors discuss a measurement approach that focuses on the following: how often do we harm patients … , how often do patients receive the appropriate interventions, how do we know we learned from defects … , and how well have we created a culture of safety. … Building on a model of structure, process, and outcome measures used to evaluate health care quality, … They provide a case-type example of their suggested process to illustrate their framework.
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psnet.ahrq.gov/web-mm/emergency-error
January 18, 2013 - Describe how variability in processes of care can increase the risk to patients undergoing emergency … , and Plan-Do-Study-Act cycles. … Decisions about how, when, and whether to operate emergently are complex and based largely on experience … be undertaken and, in the case study above, may have increased awareness of the risk of sudden deterioration … Senior physicians are likely to be able to do this more reliably than those with less experience.
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psnet.ahrq.gov/issue/managing-unexpected-sustained-performance-complex-world-3rd-edition
November 04, 2015 - The authors, professors at the University of Michigan School of Business, use both case studies and theory-based … analysis to explain the methods that result in organizational mindfulness, and, through it, a more robust … What Do We Do? … August 16, 2016
To Do No Harm: Ensuring Patient Safety in Health Care Organizations. … test new healthcare facilities: a proactive and innovative approach to healthcare system safety.
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psnet.ahrq.gov/issue/how-two-rights-can-make-wrong
November 09, 2016 - Newspaper/Magazine Article
How two rights can make a wrong. … Citation Text:
How two rights can make a wrong. Markel H. … two rights can make a wrong. … October 5, 2016
Measurement of diagnostic errors is a key first step to their reduction … June 13, 2011
What drugs do you take?
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psnet.ahrq.gov/node/49654/psn-pdf
June 01, 2012 - Describe how communication lapses can lead to errors and adverse events in the transfer of patients … Although it is difficult to accurately determine how many patients
are transferred each year worldwide … In addition to these emergent transfers, many
transfers do involve medically stable patients and are … transport services–a case study. … Do specialist transport personnel improve
hospital outcome in critically ill patients transferred to
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psnet.ahrq.gov/issue/frustrating-case-incident-reporting-systems
June 22, 2022 - This commentary discusses the limitations of incident reporting systems and provides suggestions for how … to identify adverse events. … A prospective observational cohort. … July 5, 2017
A primer on PDSA: executing plan–do–study–act cycles in practice, not just … September 29, 2021
Teaching medical error disclosure to physicians-in-training: a scoping
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psnet.ahrq.gov/issue/positive-approaches-safety-learning-what-we-do-well
September 15, 2021 - Positive approaches to safety: learning from what we do well. … September 15, 2021
A qualitative study of what care workers do to provide patient safety … December 14, 2022
How do hospital inpatients conceptualise patient safety? … March 24, 2021
How do patients respond to safety problems in ambulatory care? … 1,500 avoidable deaths a year—and aim to do even better.
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psnet.ahrq.gov/issue/do-you-have-re-examine-reconsider-your-diagnosis-checklists-and-cardiac-exam
February 06, 2014 - Study
Do you have to re-examine to reconsider your diagnosis? … Do you have to re-examine to reconsider your diagnosis? Checklists and cardiac exam. … An AHRQ WebM&M commentary discusses a missed physical examination finding that led to a diagnostic … Do you have to re-examine to reconsider your diagnosis? Checklists and cardiac exam. … April 10, 2019
Comfort with uncertainty: reframing our conceptions of how clinicians
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psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps
February 24, 2011 - Several anecdotes illustrate the role communication failures played in these mishaps and how common these … November 1, 2023
Primary care teams' reported actions to improve medication safety: a … case study. … step toward high reliability: implementation of a daily safety brief in a children's hospital. … December 30, 2014
Hospital do-not-resuscitate orders: why they have failed and how to
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integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/build-patient-understanding-setbacks-and-how-deal-them
June 01, 2022 - is a relapse and symptoms begin to worsen. … how to respond. … to do to prevent setbacks, how to recognize the onset of a setback, and how to respond, including when … How Do You Do It? … study reviews tools used by the Community Health Plan of Washington to support behavioral health integration
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psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
April 26, 2023 - A case study last year Illustrated one of the technological issues, in this case a manual keystroke … A study on “do not give” alerts found that clinicians modified their orders to comply with alert recommendations … Second, more work is needed on system usability, how the systems are integrated into workflows, and how … For example, when a scribe encounters a CDS alert, do they alert the clinician in all cases? … a case study using the UP-Fall detection dataset.
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case6.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Case 6. … Studies
Introduction to the Case Studies
Case 1. … study on LHC. ee The case study methods, including the criteria for selection of the projects for analysis … Return to Contents
Description of Horizon Hospital
This case study reports on the replacement … In our other case studies of Lean, barriers were usually mentioned much more often than facilitators.
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/smoking-use-ready-or-not.pdf
June 02, 2025 - (Jacquie will be the patient voice during this webinar)
3 Patient Case Study
Carol: We’re going … But, Doc, I’m just not ready to
give them up.”
Carol: So, what do you say and do next? … Why do so few receive treatment? And
how can we do better? … a staff member call to find out how it’s going. … Addressing Tobacco Use
2 Welcome by Carol Ripley-Moffitt, MDiv, CTTS
3 Patient Case Study
4 Objectives