-
psnet.ahrq.gov/node/33697/psn-pdf
June 01, 2010 - emergency
department (ED) patient safety and identify solutions by deconstructing care into three realms: individual … Individual Provider Issues
The EP workforce is diverse, and practitioners have varied training and experience … Individual Patient Issues
Many patient characteristics create diagnostic challenges, particularly in … (Go to table citation in the text)
Individual Provider Issues Patient Issues
Environmental
System
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psnet.ahrq.gov/node/33782/psn-pdf
March 01, 2015 - Unfavorable
rates arising from erroneous data or analyses can trigger external inquiries that stigmatize individual … hospital clinicians or administrators to easily pinpoint
correctable processes of care at the level of individual … Even within a hospital whose R-AHMR seems
reasonable, individual diagnoses and procedures may demonstrate … on mortality rates
R-AHMRs may be more suited to monitoring changes in mortality over time within individual
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psnet.ahrq.gov/web-mm/wrong-route-nutrients
September 04, 2010 - In the current case study, role clarity, safe systems, and individual responsibility are all at issue … Building safe systems does not negate individual accountability. … Although clearly there is individual accountability here, there is also great opportunity to reflect … Leaders should be well versed in assessing system issues and individual accountabilities with the capabilities
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psnet.ahrq.gov/node/33830/psn-pdf
March 22, 2016 - Estimates of the population toll of deaths from medical error are extrapolations from individual
studies … Some hospitals conduct standardized reviews of deaths in order to identify individual clinician issues … Regardless, individual hospitals
almost certainly experience several preventable deaths each year, and
-
psnet.ahrq.gov/node/33799/psn-pdf
January 01, 2015 - enrolled 1425 nurses and physicians on 54 ICU teams from 48 different
hospitals, evaluated the effect of individual … Higher individual burnout scores were related to poorer overall safety grades. … of clarification of values, professional, and
personal goals, along with strategies for accessing individual
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psnet.ahrq.gov/node/861292/psn-pdf
January 24, 2024 - deficiencies-community-care-network-credentialing-process-former-va-surgeon-and-veterans
https://psnet.ahrq.gov/primer/individual-clinician-performance-issues
-
psnet.ahrq.gov/node/855423/psn-pdf
November 15, 2023 - Resistance
or endorsement at the individual surgeon level remains a significant factor in SSC completion
-
psnet.ahrq.gov/node/46880/psn-pdf
April 25, 2018 - This commentary reviews individual and
organizational tactics to address incivility in nursing.
-
psnet.ahrq.gov/node/46767/psn-pdf
January 17, 2018 - The authors suggest that individual knowledge coupled with the power
of technology can help physicians
-
psnet.ahrq.gov/node/34773/psn-pdf
March 08, 2017 - Topics covered include a student’s experience with error, individual response
to making a mistake, and
-
psnet.ahrq.gov/node/46927/psn-pdf
April 04, 2018 - https://psnet.ahrq.gov/issue/clinician-well-being-knowledge-hub
Clinician burnout can detract from individual
-
psnet.ahrq.gov/node/47373/psn-pdf
November 14, 2018 - The
author highlights how accountability enables individual and organizational learning through constructive
-
psnet.ahrq.gov/node/37902/psn-pdf
July 09, 2008 - judged to be preventable based on
retrospective review, preventable deaths were not correlated with individual
-
psnet.ahrq.gov/node/43961/psn-pdf
August 02, 2015 - protocol to enhance the safety of deprescribing by considering
the medication therapy needs of each individual
-
psnet.ahrq.gov/node/42380/psn-pdf
December 29, 2014 - -
improvement
Implementation of dashboards that displayed medication administration errors at the individual
-
psnet.ahrq.gov/node/43022/psn-pdf
May 29, 2014 - outcomes,
this study found that simulating the event identified more system errors and focused less on individual
-
psnet.ahrq.gov/node/44910/psn-pdf
March 09, 2016 - systematically-identified-failure-route-successful-health-system
Identifying and addressing organizational factors that enable individual
-
psnet.ahrq.gov/node/45058/psn-pdf
February 18, 2017 - This
commentary describes the Dutch national reporting system effort to encourage individual hospital
-
psnet.ahrq.gov/node/34751/psn-pdf
March 07, 2005 - are due to systems factors, not moral
lapses, and thus the tort system, which focuses on assigning individual
-
psnet.ahrq.gov/node/47075/psn-pdf
November 21, 2018 - authors, STAMP analysis produced more systems solutions compared to RCA, which primarily
suggests individual-level