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Total Results: 7,488 records

Showing results for "involved".

101. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. | PSNet
     psnet.ahrq.gov/issue/missed-and-delayed-diagnoses-emergency-department-study-closed-malpractice-claims-4-liability
     March 02, 2011 - Errors involved a broad range of patients and conditions.  … physician judgment or knowledge), but system factors (ie, fatigue or communication breakdowns) were involved

102. Supporting clinicians after adverse events: development of a clinician peer support program. | PSNet
     psnet.ahrq.gov/issue/supporting-clinicians-after-adverse-events-development-clinician-peer-support-program
     April 24, 2018 - victim phenomenon refers to the emotional and psychological toll experienced by clinicians who are involved … implementation and early effects of a second victim peer support program at an academic medical center, which involved

103. Devastatingly human: an analysis of registered nurses' medication error accounts. | PSNet
     psnet.ahrq.gov/issue/devastatingly-human-analysis-registered-nurses-medication-error-accounts
     June 27, 2018 - qualitative study provides vivid insight into the emotional distress experienced by clinicians who are involved … March 2, 2012 Nurses relate the contributing factors involved in medication errors.

104. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867676/psn-pdf
     February 26, 2025 - Communication and Remediation Ongoing and timely communication with healthcare staff, patients, and families involved … In the aftermath of a patient safety event, healthcare staff involved could face feelings of guilt, … Staff involved may feel personally responsible for the patient safety event and question their own knowledge … For more information, see related primer, Second Victims: Support for Clinicians Involved in Errors … https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events

105. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45009/psn-pdf
     March 30, 2016 - https://psnet.ahrq.gov/issue/fatal-mistakes Health professionals involved in medical errors experience … psnet.ahrq.gov/issue/medical-error-second-victim https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events … suffering-silence-qualitative-study-second-victims-adverse-events https://psnet.ahrq.gov/issue/supporting-involved-health-care-professionals-second-victims-following-adverse-health-event

106. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44645/psn-pdf
     July 01, 2017 - post-traumatic-stress-disorder-amongst-surgical-trainees-unrecognised-risk Physicians who experience adverse effects after being involved … post-traumatic-stress-disorder-amongst-surgical-trainees-unrecognised-risk https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events … https://psnet.ahrq.gov/issue/medical-error-second-victim https://psnet.ahrq.gov/issue/supporting-involved-health-care-professionals-second-victims-following-adverse-health-event

107. Patient Safety Executive Development Program | PSNet
     psnet.ahrq.gov/training-catalog/patient-safety-executive-development-program
     provide direction to health care organizations on the key strategic, clinical, and operational components involved

108. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866350/psn-pdf
     July 24, 2024 - living-aftermath-second-victim-experience-among-certified-registered-nurse- anesthetists Many healthcare staff who are involved … living-aftermath-second-victim-experience-among-certified-registered-nurse-anesthetists https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events

109. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44316/psn-pdf
     March 20, 2017 - how a second victim intervention program participating with a PSO can provide support for clinicians involved … new-patient-safety-organizations-lower-roadblocks-medical-error-reporting https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events … https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events https

110. "SWARMing" to improve patient care: a novel approach to root cause analysis. | PSNet
     psnet.ahrq.gov/issue/swarming-improve-patient-care-novel-approach-root-cause-analysis
     September 23, 2020 - The process begins with a preliminary investigation into what happened and who was involved, followed … by an in-person meeting with an interdisciplinary team and any staff directly involved in the event.

111. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47187/psn-pdf
     September 05, 2018 - victim phenomenon refers to the emotional and psychological toll experienced by clinicians who are involved … implementation and early effects of a second victim peer support program at an academic medical center, which involved … supporting-clinicians-after-adverse-events-development-clinician-peer-support-program https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events

112. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/858170/psn-pdf
     December 13, 2023 - Nearly 50% of incidents involved clinical processes or procedures, and 25% involved documentation errors

113. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45441/psn-pdf
     September 21, 2016 - Investigators surveyed more than 900 clinicians involved in a patient safety incident across 33 Belgian … authors concluded that health care organizations should focus on appropriately supporting providers involved … burnout-and-medical-errors-among-american-surgeons https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events

114. Caring for our own: deploying a systemwide second victim rapid response team. | PSNet
     psnet.ahrq.gov/issue/caring-our-own-deploying-systemwide-second-victim-rapid-response-team
     September 19, 2016 - context for and development of an innovative RRS to care for the second victim —a health care provider involved … February 20, 2019 Supporting involved health care professionals (second victims) following

115. The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study. | PSNet
     psnet.ahrq.gov/issue/frequency-intravenous-medication-administration-errors-related-smart-infusion-pumps
     June 27, 2018 - this study, direct observation of nurses using smart pumps revealed that 60% of medication infusions involved … The most common errors involved incorrect infusion rates and workarounds like bypassing the smart pump

116. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. | PSNet
     psnet.ahrq.gov/issue/analysis-surgical-errors-closed-malpractice-claims-4-liability-insurers
     February 17, 2011 - Most cases involved more than one clinician, and 31% involved multiple phases of care (eg, intraoperative

117. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865873/psn-pdf
     May 15, 2024 - with technology designed to prevent them, medication errors continue to occur, often causing staff involved … review-medication-errors-and-second-victim-pediatric-pharmacy https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events

118. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866317/psn-pdf
     July 17, 2024 - "Second victim syndrome" occurs when an adverse event or error has a negative emotional impact on involved … bone-break-hot-debrief-tool-reduce-second-victim-syndrome-nurses https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events

119. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/856590/psn-pdf
     November 29, 2023 - Organizational factors and team composition presented challenges, particularly the inclusion of staff closely involved … root-cause-analysis-health-care-joint-commission-guide-analysis-and-corrective-action https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events

120. Tough Call: Addressing Errors From Previous Providers | PSNet
     psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
     July 17, 2024 - But if you were the involved clinician, how would you want to be made aware? … In the present case, Reason's algorithm may define the error as blameless if the involved clinician acted … However, if the involved professional had a history of unsafe acts, the algorithm recognizes the need … If this occurred in the appropriate culture of patient safety, it would be expected that the involved … At this level, an authority figure may direct the involved professional to participate in a practice