-
psnet.ahrq.gov/issue/hidden-curriculum-and-residents-attitudes-about-medical-error-disclosure-comparison-surgical
September 30, 2020 - Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions
-
psnet.ahrq.gov/issue/leadership-strategies-medical-school-deans-promote-quality-and-safety
August 10, 2022 - mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions
-
psnet.ahrq.gov/issue/adverse-drug-event-reporting-intensive-care-units-survey-current-practices
December 16, 2020 - Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions
-
psnet.ahrq.gov/issue/pediatric-radiology-malpractice-claims-characteristics-and-comparison-adult-radiology-claims
December 01, 2021 - mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions
-
psnet.ahrq.gov/issue/tort-reform-and-patient-safety-movement-seeking-common-ground
August 04, 2021 - Disclosing medical errors to patients: a challenge for health care professionals and institutions
-
psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - And yet, individuals and institutions within health care have a poor record of addressing
these issues … To maximize the patient safety benefits of complaints, individuals and institutions need to foster an … Individuals and institutions must proactively support doctors with multiple complaints to learn from
-
psnet.ahrq.gov/node/33618/psn-pdf
September 01, 2005 - Interestingly, as
institutions struggle with how to improve handoffs specifically, and how to accurately … described in this space, the law mandating certain nurse-to-patient ratios in California has led
some institutions … us a step closer to understanding how practices can be successfully
implemented at a wide range of institutions
-
psnet.ahrq.gov/node/33628/psn-pdf
February 01, 2006 - RW: One point you made nicely in your book is that, although institutions obsess over how to handle the … The challenge for institutions is to look at the conduct of the individual and decide whether or not … For many institutions and providers, some
errors probably would not have come to light except for the
-
psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - Focus on single incidents and institutions
Incidents tend to be investigated in isolation—single events … within single institutions. … analytical methods, and relevant theories; patients and families be meaningfully engaged in the process; institutions
-
psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - hours, further tightened in 2011, markedly increased the number of handoffs among trainees in training institutions … have tried diverse approaches tailored to the culture, workforce, and patient population of particular institutions … rates, important data emerged supporting the premise that such penalties may unfairly penalize certain institutions
-
psnet.ahrq.gov/web-mm/reconciling-records
September 01, 2017 - reconciliation, a process emphasized by the Joint Commission National Patient Safety Goals.( 2 ) However, institutions … information available from the EHR or other sources such as pharmacy data, other providers, and health care institutions … patients, family members, caregivers, and other health care team members from their own or external institutions
-
psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
May 01, 2013 - 1% of base hospital DRG payments are withheld, with value-based incentive payments awarded later to institutions … In addition to Value-Based Purchasing, the Readmission Reductions Program penalizes institutions with … The second is why haven't even those very leading institutions been able to solve all of the problems … And the small number of leading institutions ultimately represent a small amount of care and what I want … Institutions located in communities with a high proportion of minority and poor patients are much more
-
psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
May 01, 2013 - The second is why haven't even those very leading institutions been able to solve all of the problems … And the small number of leading institutions ultimately represent a small amount of care and what I want … Institutions located in communities with a high proportion of minority and poor patients are much more … 1% of base hospital DRG payments are withheld, with value-based incentive payments awarded later to institutions … In addition to Value-Based Purchasing, the Readmission Reductions Program penalizes institutions with
-
psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - Many institutions have developed multipronged approaches to enhancing postdischarge care. … HK : We are at the point where we need to find some institutions willing to test this—I firmly believe … that it will pay dividends for the patients and the institutions. … For the future, we need to create the means by which consortia of institutions can come together and … If 10 institutions are willing to work together and could collectively achieve a gain, then they could
-
psnet.ahrq.gov/issue/first-do-less-harm-confronting-inconvenient-problems-patient-safety
March 29, 2007 - Organizational culture and its implications for infection prevention and control in healthcare institutions
-
psnet.ahrq.gov/issue/physician-leadership-key-creating-safer-more-reliable-health-care-system
November 17, 2009 - November 17, 2009
Barriers to implementation of patient safety systems in healthcare institutions
-
psnet.ahrq.gov/issue/managing-risk-point-care-preventing-errors
February 06, 2018 - mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.131_slideshow.ppt
August 01, 2006 - Photograph reprinted with permission of The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions … Photograph reprinted with permission of The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
June 01, 2004 - Recognize the emotional impact that errors have on health care workers
List specific steps that institutions … Take-Home Points
The link between error disclosure and quality improvement should be emphasized
Institutions
-
psnet.ahrq.gov/issue/disclosing-errors-affect-multiple-patients
April 19, 2017 - Disclosing medical errors to patients: a challenge for health care professionals and institutions