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psnet.ahrq.gov/node/34667/psn-pdf
January 17, 2018 - Lessons from the Denver medication error/criminal
negligence case: look beyond blaming individuals. … /psnet.ahrq.gov/issue/lessons-denver-medication-errorcriminal-negligence-case-look-beyond-
blaming-individuals … The authors discuss the need to look beyond individuals and focus on the multiple
system failures that … ://psnet.ahrq.gov/issue/lessons-denver-medication-errorcriminal-negligence-case-look-beyond-blaming-individuals … ://psnet.ahrq.gov/issue/lessons-denver-medication-errorcriminal-negligence-case-look-beyond-blaming-individuals
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psnet.ahrq.gov/node/42768/psn-pdf
November 27, 2013 - Findings and Lessons From the Improving Management
of Individuals With Complex Health Care Needs Through …
https://psnet.ahrq.gov/issue/findings-and-lessons-improving-management-individuals-complex-health-care … https://psnet.ahrq.gov/issue/findings-and-lessons-improving-management-individuals-complex-health-care-needs-through … https://psnet.ahrq.gov/issue/findings-and-lessons-improving-management-individuals-complex-health-care-needs-through
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psnet.ahrq.gov/node/33620/psn-pdf
September 01, 2005 - Williams suggests that individuals directly involved in an error should participate in the root cause … While we agree that such
individuals should participate in the RCA process, we don't believe that they … should be members of the
RCA team, for the following reasons: (1) such individuals often feel guilt … This allows the RCA team to appreciate the barriers and
obstacles faced by the individuals involved … We ask such individuals
to describe the incident and to suggest improvements in care delivery that could
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psnet.ahrq.gov/issue/how-timely-diagnosis-lung-cancer-cohort-study-individuals-lung-cancer-presenting-ambulatory
September 14, 2022 - Cohort study of individuals with lung cancer presenting in ambulatory care in the United States. … Cohort study of individuals with lung cancer presenting in ambulatory care in the United States. … Cohort study of individuals with lung cancer presenting in ambulatory care in the United States.
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psnet.ahrq.gov/node/48137/psn-pdf
July 17, 2019 - In this survey study in oncology, nearly 300 individuals, including physicians, nurse
practitioners, … Investigators found that individuals describing a greater degree of
electronic health record use reported … lower safety culture scores, and individuals who rated communication
higher also perceived safety culture
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psnet.ahrq.gov/issue/human-error-models-and-management
November 18, 2015 - The person approach focuses on blaming individuals, whereas the system approach concentrates on the conditions … under which individuals work. … More
Related Resources
The rise of human factors: optimising performance of individuals
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psnet.ahrq.gov/issue/idea-safety-training-improve-critical-thinking-individuals-and-teams
May 25, 2016 - Commentary
An IDEA: safety training to improve critical thinking by individuals and … An IDEA: Safety Training to Improve Critical Thinking by Individuals and Teams. … An IDEA: Safety Training to Improve Critical Thinking by Individuals and Teams.
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psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled-nursing
October 30, 2024 - Identify one or two individuals who can serve as the primary point (or points) of contact at each site … The SNF and hospital are responsible for identifying these individuals, but the role is often filled … Identify individuals to serve in key innovation clinical roles. … This is particularly true for frail individuals or for those with cognitive impairment who cannot play … Identify individuals to serve in key innovation clinical roles.
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psnet.ahrq.gov/issue/findings-and-lessons-improving-management-individuals-complex-health-care-needs-through
October 02, 2013 - Book/Report
Findings and Lessons From the Improving Management of Individuals With … Citation Text:
Findings and Lessons From the Improving Management of Individuals With Complex Health … Citation
Citation Text:
Findings and Lessons From the Improving Management of Individuals
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psnet.ahrq.gov/perspective/response-getting-root-matter-june-2005
June 01, 2005 - Williams suggests that individuals directly involved in an error should participate in the root cause … While we agree that such individuals should participate in the RCA process, we don't believe that they … should be members of the RCA team, for the following reasons: (1) such individuals often feel guilt … This allows the RCA team to appreciate the barriers and obstacles faced by the individuals involved with … We ask such individuals to describe the incident and to suggest improvements in care delivery that could
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psnet.ahrq.gov/issue/experimental-evidence-structured-information-sharing-networks-reducing-medical-errors
December 15, 2021 - Collective intelligence posits that the judgment (in this case, diagnostic accuracy) of a group of individuals … information-sharing improved not only group diagnostic accuracy, but also diagnostic accuracy of the individuals
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psnet.ahrq.gov/issue/beyond-clinical-team-evaluating-human-factors-oriented-training-non-clinical-professionals
March 12, 2025 - Nonclinicians such as hospital administrators or law enforcement officials frequently encounter individuals … October 5, 2021
The rise of human factors: optimising performance of individuals and
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psnet.ahrq.gov/node/49693/psn-pdf
October 01, 2013 - Affected individuals are often called transgender. … Unfortunately, this case describes a common experience for transgender individuals, who often report … Moreover, transgender individuals often do
not disclose their gender identity because of stigma and … Transgender individuals commonly encounter a wide variety of
discriminatory barriers. … Transitioning transgender individuals face a number of patient safety issues.
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psnet.ahrq.gov/node/72737/psn-pdf
February 09, 2021 - focus on care coordination related to social determinants of
health, peer support, and connecting individuals … The all-cause mortality rate among individuals in the program is 81%
lower than in individuals with … Innovation Patient Safety Focus
The program has succeeded in reducing mortality among individuals suffering … Work to establish strong partnership with champions in care settings that frequently encounter
individuals … a disease that requires specialized treatment helps to alleviate some of this
stigma and encourage individuals
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psnet.ahrq.gov/node/851459/psn-pdf
July 19, 2023 - Based on a sample of
over 700,000 veterans, this study found that Black and Hispanic individuals consumed … similar amounts of
alcohol to White individuals but were more likely to be diagnosed with alcohol use
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psnet.ahrq.gov/node/865871/psn-pdf
May 15, 2024 - This analysis of 64,441 deliveries in
Massachusetts in 2019 found that individuals delivering in hospitals … Among the one-third of individuals with a high-risk
obstetric condition, 13% delivered at a hospital
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psnet.ahrq.gov/node/44689/psn-pdf
February 24, 2018 - data from five ethnographic case studies to illustrate the fundamental interdependence of systems
and individuals … The authors argue apportioning responsibility between systems and the
individuals within them leads … Senior author Mary Dixon-Woods
elaborates on the relationship between individuals and systems in a PSNet
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psnet.ahrq.gov/issue/stigmatizing-language-expressed-towards-individuals-current-or-previous-oud-who-have-pain-and
January 09, 2011 - Study
Stigmatizing language expressed towards individuals with current or previous … Stigmatizing language expressed towards individuals with current or previous OUD who have pain and cancer … Stigmatizing language expressed towards individuals with current or previous OUD who have pain and cancer
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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Innovation Patient Safety Focus
The program has succeeded in reducing mortality among individuals suffering … and focus on care coordination related to social determinants of health, peer support, and connecting individuals … The all-cause mortality rate among individuals in the program is 81% lower than in individuals with untreated … Work to establish strong partnership with champions in care settings that frequently encounter individuals … a disease that requires specialized treatment helps to alleviate some of this stigma and encourage individuals
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psnet.ahrq.gov/issue/two-cultures-modern-science-and-technology-safety-and-validity-does-medicine-have-update
January 12, 2022 - A ‘traditional culture’ leaves error control up to individuals and groups of healthcare practitioners … modern scientific culture’ considers errors as inevitable and pervasive throughout medicine and beyond individuals