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Total Results: 354 records

Showing results for "instances".

1. Error | PSNet
   psnet.ahrq.gov/taxonomy/term/3475
   In other words, there are likely many more instances in which the provision of additional diagnostic, … therapeutic, or preventive modalities would have improved care than there are instances in which the

2. Behaviors that undermine a culture of safety. | PSNet
   psnet.ahrq.gov/issue/behaviors-undermine-culture-safety
   April 24, 2024 - programs, "zero tolerance" policies, and clear processes for detecting, reporting, and documenting all instances

3. Potentially inappropriate prescribing in long-term care and its relationship with probable delirium. | PSNet
   psnet.ahrq.gov/issue/potentially-inappropriate-prescribing-long-term-care-and-its-relationship-probable-delirium
   April 19, 2023 - Researchers found that residents with three or more instances of PIP (measured by STOPP/START and … Beers criteria) were significantly more likely to have probable delirium compared to residents with no instances

4. Forcing Function | PSNet
   psnet.ahrq.gov/taxonomy/term/3478
   August 18, 2020 - Forcing Function An aspect of a design that prevents a target action from being performed or allows its performance only if another specific action is performed first. For example, automobiles are now designed so that the driver cannot shift into reverse without first putting her foot on the brake pedal. Forcing func…

5. Infant deaths associated with cough and cold medications—two states, 2005. | PSNet
   psnet.ahrq.gov/issue/infant-deaths-associated-cough-and-cold-medications-two-states-2005
   June 12, 2013 - The investigation found three instances in which these medications were considered the underlying cause

6. Glossary | PSNet
   psnet.ahrq.gov/glossary
   January 01, 2003 - In other words, there are likely many more instances in which the provision of additional diagnostic, … therapeutic, or preventive modalities would have improved care than there are instances in which the

7. Glossary | PSNet
   psnet.ahrq.gov/glossary-0
   January 01, 2003 - In other words, there are likely many more instances in which the provision of additional diagnostic, … therapeutic, or preventive modalities would have improved care than there are instances in which the

8. Forcing Function | PSNet
   psnet.ahrq.gov/glossary/forcing-function
   September 13, 2021 - Forcing Function September 13, 2021 Anonymous (not verified) An aspect of a design that prevents a target action from being performed or allows its performance only if another specific action is performed first. For example, automobiles are now designed so that the driver cannot shift into reverse without first…

9. Latent Error (or Latent Condition) | PSNet
   psnet.ahrq.gov/glossary/latent-error-or-latent-condition
   September 13, 2021 - Latent Error (or Latent Condition) September 13, 2021 Anonymous (not verified) The terms active and latent as applied to errors were coined by Reason . Latent errors (or latent conditions) refer to less apparent failures of organization or design that contributed to the occurrence of errors or allowed them…

10. Latent Error (or Latent Condition) | PSNet
    psnet.ahrq.gov/taxonomy/term/3488
    December 12, 2020 - Latent Error (or Latent Condition) The terms active and latent as applied to errors were coined by Reason . Latent errors (or latent conditions) refer to less apparent failures of organization or design that contributed to the occurrence of errors or allowed them to cause harm to patients. For instance, whereas …

11. Mental Models | PSNet
    psnet.ahrq.gov/taxonomy/term/3466
    Mental Models Mental models are psychological representations of real, hypothetical, or imaginary situations. Scottish psychologist Kenneth Craik (1943) first proposed mental models as the basis for anticipating events and explaining events (i.e., for reasoning). Though easiest to conceptualize in terms of mental pic…

12. In Conversation with…Peter J. Pronovost, MD, PhD | PSNet
    psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
    June 01, 2005 - In Conversation with…Peter J. Pronovost, MD, PhD June 1, 2005  Also Read an Essay Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Editor's Note: Peter J. Pronovost, MD, PhD, is M…

13. Situational Awareness | PSNet
    psnet.ahrq.gov/taxonomy/term/3440
    Situational Awareness Situational awareness refers to the degree to which one's perception of a situation matches reality. In the context of crisis management, where the phrase is most often used, situational awareness includes awareness of fatigue and stress among team members (including oneself), environmental thre…

14. Periodic Issue | PSNet
    psnet.ahrq.gov/periodic-issue/periodic-issue-389
    April 26, 2023 - Numerous comments from caregivers are provided, describing instances of entanglements and strategies … This article shares several instances of learning from event reports submitted in the state of Pennsylvania

15. Periodic Issue | PSNet
    psnet.ahrq.gov/periodic-issue/periodic-issue-424
    January 04, 2024 - Researchers found that residents with three or more instances of PIP (measured by STOPP/START and Beers … criteria) were significantly more likely to have probable delirium compared to residents with no instances

16. Battle Buddy Pocket Card - Final (1) (pdf file)
    psnet.ahrq.gov/sites/default/files/2021-09/Battle%20Buddy%20Pocket%20Card%20-%20final%20(1).pdf
    January 01, 2021 - Battle Buddies (BBs) are usually chosen by a third party but in some instances pair up spontaneously

17. Failure Mode and Effect Analysis (FMEA) | PSNet
    psnet.ahrq.gov/taxonomy/term/3477
    Failure Mode and Effect Analysis (FMEA) A common process used to prospectively identify error risk within a particular process. FMEA begins with a complete process mapping that identifies all the steps that must occur for a given process to occur (e.g., programming an infusion pump or preparing an intravenous medicat…

18. Periodic Issue | PSNet
    psnet.ahrq.gov/periodic-issue/periodic-issue-274
    January 29, 2021 - This draft guidance seeks to provide a structure for industry to reduce instances of drug name confusion … This publication examined 250 instances of maternal and baby harm at a National Health Service trust

19. Interpreting the Patient Safety Literature | PSNet
    psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
    June 01, 2005 - Interpreting the Patient Safety Literature Kaveh G. Shojania, MD | June 1, 2005  Also Read a Conversation View more articles from the same authors. Save Save to your library Print Share Facebook Twitter Linkedin Copy URL…

20. Swiss Cheese Model | PSNet
    psnet.ahrq.gov/taxonomy/term/3460
    November 14, 2020 - Swiss Cheese Model Reason developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. In the model, each slice of cheese represents a safety barrier or precaution relevant to a particular …