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1401. Signout Fallout | PSNet
      psnet.ahrq.gov/web-mm/signout-fallout
      November 16, 2022 - to teach faculty supervisors the I-PASS Method and to do assessment observations; A process- and culture-change … Because handoff processes become entrenched in institutional culture, efforts to improve them require … more than just training, assessment, and feedback.

1402. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846975/psn-pdf
      March 28, 2023 - Can you please tell us just a little bit about yourself and your current role? … Celebrities have spoken about it, and the culture of social media has normalized talking about mental … I experienced a perinatal mental health condition myself, and I remember thinking that I must just not

1403. Measurement of Patient Safety | PSNet
      psnet.ahrq.gov/primer/measurement-patient-safety
      September 15, 2024 - May 31, 2023 The barriers and enhancers to trust in a just culture in hospital

1404. In Conversation with...Patrick Tighe about Artificial Intelligence | PSNet
      psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
      March 27, 2024 - In some cases, just taking that second look at a problem with this set of AI-fueled lenses leads us to … First, we have a patient who is hypotensive, tachycardic with fever, and positive blood cultures immediately … It really humbled us and made us realize that just being able to predict an outcome is not the same as … It’s a really exciting opportunity to not just keep an eye on the patient, but quantify certain aspects … It’s not just what we did, it’s the how we care for somebody.

1405. The Unfamiliar Catheter | PSNet
      psnet.ahrq.gov/web-mm/unfamiliar-catheter
      November 01, 2006 - A simulation-based "just in time" and "just in place" central venous catheter education program. … Patient Safety March 27, 2024 WebM&M Cases Culture

1406. Safety in Radiology | PSNet
      psnet.ahrq.gov/perspective/safety-radiology
      October 01, 2013 - Essentially we're imaging the chest three or four times, when we used to just image it once. … The brain perfusion scan had just become a common study type, even for patients who should not have had … One is the effect that you see right away, and it means the doses are just really high so you see the … We just received a Patient Centered Outcomes Research Institute grant focused on this topic, and our … August 22, 2018 Improving patient safety: effects of a safety program on performance and culture

1407. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49414/psn-pdf
      September 01, 2003 - However, post-operatively, the patient developed fevers, and blood cultures grew Actinomyces. … The astute physician will remember that expertise lies not just in manual dexterity, careful surgical

1408. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49581/psn-pdf
      March 21, 2009 - The policy mandating that all new medications be given within 4 hours of being ordered had just been … Environment Dynamics: If the organization functions in a hierarchical model of patient care, move toward a culture

1409. Poorly Advanced Directives | PSNet
      psnet.ahrq.gov/web-mm/poorly-advanced-directives
      August 01, 2018 - can increase advance directive completion.( 5 ) Best practices, such as eliciting patients' values, beliefs … Just as with DNR orders, family members generally cannot override a patient- and physician-signed POLST … End-of-Life Care Planning August 1, 2018 Preventing harm in the ICU—building a culture

1410. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49849/psn-pdf
      January 01, 2019 - in the availability of resources to recognize and treat acute medical problems; to appreciate this, just … a growth area.(22) Additional ways to improve patient safety in psychiatry would be to enhance the culture … and mortality conferences are uncommon in psychiatry.(23) Moreover, error reporting systems—and the culture … Identifying and reducing medication errors in psychiatry: creating a culture of safety through the use

1411. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867651/psn-pdf
      February 26, 2025 - on Normal Accidents and HROs 1990s and on Swiss Cheese and Safety Management 2000s and on Safety Culture … viewed, as well as the utility of the concept of human error.1, 13-15 This questioning of long held beliefs … enables the incorrect assumption that observations in this limited subset of cases demonstrate not just … Hollnagel terms this the causality credo, which he defines as “the belief that adverse outcomes happen … and early adoption.23 Work as Done and Work as Imagined “Work-as-Done” and “Work-as-Imagined” are just

1412. The Role of Graduate Medical Education (GME) in Improving Patient Safety | PSNet
      psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
      February 01, 2010 - They also recommended improvements to the culture of safety through error detection, reporting, and monitoring … is now a required element for accreditation for all hospitals.( 23 ) Collaborations with Others Just … We are just now graduating our first group of general surgeons under these standards. … We need to begin to talk about those issues because it may not just be duty hours. … And we need to get at all of those issues, not just the duty hours.

1413. In Conversation with…Thomas J. Nasca, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
      February 01, 2010 - But what it does mean is that the issue is much more complex than just giving them enough time to sleep … We are just now graduating our first group of general surgeons under these standards. … We need to begin to talk about those issues because it may not just be duty hours. … And we need to get at all of those issues, not just the duty hours. … They also recommended improvements to the culture of safety through error detection, reporting, and monitoring

1414. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49447/psn-pdf
      June 01, 2004 - Beyond these considerations, communication and culture may have played an additional, subtler role in … communication to be one of the most common contributing factors to medical mishaps.(12) Communication is not just

1415. Out of Sight, Out of Mind: Out-of-Office Test Result Management | PSNet
      psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
      September 01, 2007 - Although a variety of approaches might be effective depending on local practice culture and EHR capabilities … However, patients desire more than just access to test results—they also want to know their clinicians … Improving test result follow-up through electronic health records requires more than just an alert.

1416. Delay in Malignancy Diagnosis Reflects Systemic Failures | PSNet
      psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
      September 25, 2019 - July 19, 2023 Rooting an error review process in just culture: lessons learned. … WebM&M Cases Delayed Recognition of a Positive Blood Culture

1417. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49651/psn-pdf
      May 01, 2012 - Blood cultures were positive for E. coli, and appropriate antibiotic therapy was initiated. … of intraventricular gentamycin with resolution of ventriculitis as documented by negative E. coli cultures … they do.(11) Therefore, in handoffs, senders underestimate how much information receivers need, not just

1418. Peripheral IV in Too Long | PSNet
      psnet.ahrq.gov/web-mm/peripheral-iv-too-long
      September 15, 2011 - While most cases of phlebitis are noninfectious (just inflammation of the vein), this can progress to … Blood cultures drawn at the time grew methicillin-resistant Staphylococcus aureus (MRSA), most likely … phlebitis.( 1,2 ) In a prospective study of 3165 patients, however, the majority of phlebitis cases were culture-negative

1419. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49699/psn-pdf
      February 01, 2014 - identifying, reporting, and analyzing medication errors, all organizations should actively cultivate a culture … identifying, reporting, analyzing, and reducing the risk of medication errors • Cultivation of a just … culture of safety Table 2.

1420. All in the History | PSNet
      psnet.ahrq.gov/web-mm/all-history
      February 28, 2011 - The paramedics had just arrived in the ED with a critically ill patient.