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Total Results: 354 records

Showing results for "instances".

121. Building a Safety Program Using Principles of Resilience Engineering | PSNet
     psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
     August 01, 2015 - Building a Safety Program Using Principles of Resilience Engineering Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019  View more articles from the same authors. Save Save to your library Print Share Face…

122. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-405
     August 30, 2023 - for improvement focus on increasing leadership engagement and use of the data collected to examine instances

123. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-414
     October 31, 2023 - This report details five wrong-site surgeries and three instances of retained surgical items at one VA

124. How could this happen? | PSNet
     psnet.ahrq.gov/issue/how-could-happen
     September 19, 2007 - Newspaper/Magazine Article How could this happen? Citation Text: Westfall SS; Mascia K. People. October 5, 2009. Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL November 4, …

125. In Conversation With… Rosemary Gibson, MSc | PSNet
     psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
     September 01, 2014 - Not only do such patients not have better outcomes, in many instances they seem to do worse.( 9 ) For

126. Techno Trip | PSNet
     psnet.ahrq.gov/web-mm/techno-trip
     May 01, 2005 - far removed from the failures themselves in ways that encourage people to view IT-based failures as instances

127. Approach to Improving Patient Safety: Communication | PSNet
     psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
     August 31, 2020 - Annual Perspective Approach to Improving Patient Safety: Communication March 10, 2021  View more articles from the same authors. Save Save to your library Print Share Facebook Twitter Linkedin Copy URL …

128. Unexpected Drawbacks of Electronic Order Sets | PSNet
     psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
     December 01, 2017 - Unexpected Drawbacks of Electronic Order Sets Save Save to your library Print Share Facebook Twitter Linkedin Copy URL John D. McGreevey III, MD | November 1, 2016 View more articles from the same authors. The Case A 70-year-old man with stag…

129. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
     December 01, 2015 - PowerPoint Presentation Spotlight Harm From Alarm Fatigue This presentation is based on the December 2015 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD, University of California, San …

130. Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know? | PSNet
     psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-disciplinary-actions-and-complaints-what-do-we-know
     July 01, 2017 - In reality, we know from pretty well established evidence that only about 2% or 3% of instances of negligent … That leads to the reality that most instances of negligent injury never are addressed in the legal system

131. Never Events | PSNet
     psnet.ahrq.gov/primer/never-events
     September 07, 2019 - Never Events Save Save to your library Print Share Facebook Twitter Linkedin Copy URL September 7, 2019 Background The term "Never Event" was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in referenc…

132. Pathologic Mistake | PSNet
     psnet.ahrq.gov/web-mm/pathologic-mistake
     July 01, 2017 - Pathologic Mistake Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Reza Alaghehbandan, MD, MSc, and Stephen S. Raab, MD | March 1, 2013 View more articles from the same authors. The Case A 32-year-old previously healt…

133. Team Training: Classroom Training vs. High-Fidelity Simulation | PSNet
     psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
     July 01, 2017 - Team Training: Classroom Training vs. High-Fidelity Simulation Stephen D. Pratt, MD and Benjamin P. Sachs, MB | March 1, 2006  View more articles from the same authors. Save Save to your library Print Share Facebook Twitter Linke…

134. Reconciling Records | PSNet
     psnet.ahrq.gov/web-mm/reconciling-records
     September 01, 2017 - Reconciling Records Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Hardeep Singh, MD, MPH; Dean F. Sittig, PhD; Maureen Layden, MD, MPH | November 1, 2010 View more articles from the same authors. The Cases   Case …

135. Polypharmacy | PSNet
     psnet.ahrq.gov/web-mm/polypharmacy
     March 01, 2007 - In most instances, medications managed by specialty pharmacies are associated with high cost or with

136. Emergent Triage Miss | PSNet
     psnet.ahrq.gov/web-mm/emergent-triage-miss
     December 20, 2023 - care unit (ICU) admissions for similar complaints and that she had required intubation in one of those instances

137. In Conversation With... James P. Bagian, MD, PE | PSNet
     psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
     April 24, 2024 - rules and guidelines that, while generally applicable and worth being followed, in certain specific instances

138. In Conversation With… David Juurlink, MD, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
     May 22, 2017 - at high doses as a treatment for chronic pain, in the US in particular we have seen doctors in some instances … DJ : I think in some instances we have. I've often been lumped into the anti-opioid camp.

139. Aviation Safety Methods: Quickly Adopted but Questions Remain | PSNet
     psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain
     January 01, 2006 - JB: It is, of course, situationally dependent because in health care there are instances where you do … JB: Well, we've had a couple of instances where people came back and told us that they probably stopped

140. Overuse as a Patient Safety Problem | PSNet
     psnet.ahrq.gov/perspective/overuse-patient-safety-problem
     September 01, 2014 - Not only do such patients not have better outcomes, in many instances they seem to do worse.( 9 ) For