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psnet.ahrq.gov/primer/debriefing-clinical-learning
September 15, 2024 - Its goals are to discuss the actions and thought processes involved in a particular clinical situation … the details of the event and to identify learning points for the staff and hospital system personnel involved … the type of debriefing to hold may include the seriousness of the event, the number of departments involved … convenience, other clinical obligations, any preexisting policies, and the personnel present and/or involved … to identify error and assign blame, but to understand why actions and decisions made sense to those involved
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psnet.ahrq.gov/node/852461/psn-pdf
August 16, 2023 - to demonstrate the role of discrimination in
the outcome and hold the clinicians and organization involved
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psnet.ahrq.gov/node/837798/psn-pdf
August 10, 2022 - of imaging results can result in harm to the patient and have legal
ramifications for the providers involved
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psnet.ahrq.gov/node/33576/psn-pdf
December 15, 2024 - A classic case of wrong-patient surgery involved a patient who underwent a
cardiac procedure intended … pause before beginning the procedure in order to
review important aspects of the procedure with all involved
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psnet.ahrq.gov/node/866084/psn-pdf
June 05, 2024 - The authors explore the risks involved in AI-
created health misinformation (AI hallucinations) or malicious
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psnet.ahrq.gov/node/866160/psn-pdf
June 19, 2024 - The authors stress that end users should be involved in the
design process.
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psnet.ahrq.gov/node/50652/psn-pdf
January 01, 2020 - Preventable adverse drug
events commonly involved anticoagulants, diuretics, insulin, and aspirin, and
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psnet.ahrq.gov/node/838192/psn-pdf
September 28, 2022 - The piece discusses how these detractors from safety were all present at the
hospital involved.
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psnet.ahrq.gov/node/60711/psn-pdf
July 22, 2020 - issue/prevalence-errors-anaphylaxis-kids-peak-multicenter-simulation-based-study
This simulation study involved
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psnet.ahrq.gov/node/73535/psn-pdf
July 28, 2021 - Medication
errors were the largest source of order errors and commonly involved antibiotics and opioid
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psnet.ahrq.gov/node/73970/psn-pdf
October 21, 2021 - and families feel about
support mechanisms after they have experienced medical error, if they were involved
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psnet.ahrq.gov/node/849613/psn-pdf
May 31, 2023 - Recommendations to minimize
similar occurrences include removing the involved device from service and
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psnet.ahrq.gov/node/851885/psn-pdf
January 01, 2024 - In particular, nurses should be involved in the development and testing of any
AI used in the nursing
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psnet.ahrq.gov/node/60842/psn-pdf
August 26, 2020 - Potentially serious errors were frequently identified at hospital
discharge and commonly involved antithrombotic
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psnet.ahrq.gov/node/837811/psn-pdf
August 10, 2022 - Panelists from the Veterans Administration, the investigator and
the technology vendor involved in the
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psnet.ahrq.gov/node/838927/psn-pdf
October 26, 2022 - Pharmacists involved in
codes reported concerns including errors with high-alert medications and communication
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psnet.ahrq.gov/node/837431/psn-pdf
June 15, 2022 - and investigations of a high-profile incident that culminated in
criminal charges for the clinician involved
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psnet.ahrq.gov/node/838187/psn-pdf
September 28, 2022 - This survey of over 500
infectious disease clinicians revealed that diagnostic delay often involved
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psnet.ahrq.gov/node/47958/psn-pdf
June 26, 2019 - patient-safety-professionals-third-victims-adverse-events
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
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psnet.ahrq.gov/node/73658/psn-pdf
September 01, 2021 - Results indicate machine learning may be useful
in understanding risk factors involved with medication