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1421. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33660/psn-pdf
      December 01, 2007 - coming in for follow-up, only for them to berate me about the terrible episode of care that they had just … Then there's a series of two or three phone calls after that, just to see how things went and whether

1422. Maternal Safety and Perinatal Mental Health | PSNet
      psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
      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

1423. WebM&M: Case Studies | PSNet
      psnet.ahrq.gov/webmm-case-studies
      March 25, 2025 - Health Literacy Improvement (11) Informed Consent (15) Culture … of Safety (39) Just Culture (1) Learning Organization (2) Red … commentary discusses appropriate management of ongoing intraoperative and postoperative bleeding and how a culture

1424. Double Dosing, by the Rules | PSNet
      psnet.ahrq.gov/web-mm/double-dosing-rules
      February 03, 2010 - The policy mandating that all new medications be given within 4 hours of being ordered had just been … Dynamics: If the organization functions in a hierarchical model of patient care, move toward a culture

1425. Spotlight: Mistaken Attribution, Diagnostic Misstep | PSNet
      psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
      July 01, 2011 - in the availability of resources to recognize and treat acute medical problems; to appreciate this, just … 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

1426. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33684/psn-pdf
      May 01, 2009 - The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. … Electronic health records: just around the corner? Or over the cliff?

1427. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care | PSNet
      psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
      June 01, 2003 - Since the patient with COPD just admitted appeared to be improving rapidly, and the other nurses were … The solutions are multifaceted, and all solutions begin with the nursing culture of the organization … This commentary has expressed both proactive and just-in-time approaches to making patients safe.

1428. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33599/psn-pdf
      August 30, 2023 - Health literacy is affected by many factors, including socioeconomic status, culture, and language.11 … program if they teach the underlying skills needed to manage health or obtain healthcare, and not just

1429. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49618/psn-pdf
      February 01, 2011 - Currently, renewal of a medical license mostly involves just passing a criminal background check and … Impeding this change in culture is the lack of robust, systematic assessment approaches, fear of retribution … The Culture Code: An Ingenious Way to Understand Why People Around the World Live and Buy as They Do

1430. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. | PSNet
      psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
      March 19, 2019 - The Differences Between Human Error, At-Risk Behavior, and Reckless Behavior Are Key to a Just Culture … Improving Diagnostic Safety and Quality April 26, 2023 Creating a stronger culture

1431. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33803/psn-pdf
      January 01, 2015 - We have made extensive progress in changing the culture in hospitals and other health care institutions … Recent estimates are around 20 million fewer people uninsured than just a few years ago. … Is that just a compelling and easy to understand story?

1432. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49465/psn-pdf
      December 22, 2021 - It makes just as much sense in the outpatient setting, and in our experience at the Palo Alto Medical … event, performing a hazard analysis, and developing prevention strategies) indicate that a healthy culture

1433. Looking for Meds in All the Wrong Places | PSNet
      psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
      June 16, 2021 - to be helpful, the instinct of all clinicians has to change from one of "this is unusual, but I'll just … Subsequently, the environmental culture needs to support and encourage clinicians to report medication

1434. Comanagement: Who's in Charge? | PSNet
      psnet.ahrq.gov/web-mm/comanagement-whos-charge
      July 01, 2011 - Just because you can, doesn't mean that you should: a call for the rational application of hospitalist … Misstep January 1, 2019 A multilevel analysis of U.S. hospital patient safety culture

1435. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
      January 01, 2008 - The resident then realized that the effusion was on the contralateral side, not the left side she had just … efforts should focus on implementing curriculum in medical errors at all levels of medical training Culture

1436. Dangerous Dapsone | PSNet
      psnet.ahrq.gov/web-mm/dangerous-dapsone
      January 10, 2011 - 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

1437. Wrong-side Bedside Paravertebral Block: Preventing the Preventable | PSNet
      psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
      August 10, 2019 - April 1, 2016 Perspective Update on Safety Culture … , 2021 WebM&M Cases Premature Closure: Was It Just

1438. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment | PSNet
      psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
      June 01, 2018 - Moreover, the issues extend beyond just intubation equipment. … August 17, 2022 Influences of leadership, organizational culture, and hierarchy on raising

1439. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33655/psn-pdf
      August 01, 2007 - We have just started the practice of opening every board quality committee meeting with a real story

1440. Patient Safety in Office-Based Care Settings | PSNet
      psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
      January 31, 2024 - harm. 5,6 Violence in healthcare settings impacts patient safety, and guidance is emerging that a culture … tools designed to increase the effectiveness of communication to improve patient safety, especially the culture … Sarah Mossburg: Could we step back from there just to touch on context? … one, and you go to an emergency room and they say, “We don’t have time to find the old CT scan, we’ll just