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psnet.ahrq.gov/node/866641/psn-pdf
September 04, 2024 - associated with an ever-increasing amount of data, limited
resources such as staff shortages, and lack
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psnet.ahrq.gov/node/852289/psn-pdf
August 09, 2023 - The problem was compounded by
a lack of attention to women voicing their concerns about procedural pain
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psnet.ahrq.gov/node/60042/psn-pdf
March 11, 2020 - This news story discusses one retail pharmacy chain's lack of transparency
regarding work conditions
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psnet.ahrq.gov/node/40393/psn-pdf
December 21, 2014 - structured-interdisciplinary-rounds-medical-teaching-unit-improving-patient-
safety
Interdisciplinary teamwork is a primary driver of safety culture, and lack
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psnet.ahrq.gov/node/49779/psn-pdf
January 01, 2017 - There is a lack of standardization to support data aggregation.
2. … There is a lack of
coordination between pump requirements and hospital capabilities. … There is a lack of standardization of terminology used in infusion systems (upstream and
downstream … There is a lack of knowledge/familiarity with infusion devices and a lack of effective training in
their … Injuries are caused by a lack of differentiation between the use of infusion devices in hospitals
and
-
psnet.ahrq.gov/node/865883/psn-pdf
May 15, 2024 - This piece explores the lack of knowledge regarding the intersection of EHRs and
diagnostic error.
-
psnet.ahrq.gov/node/33695/psn-pdf
April 01, 2010 - (1-5) Although there are a number of contributors to this slow rate of progress,
one factor is the lack … timeliness, safety,
and patient-centeredness of health care delivery services have been hindered by the lack … Safe Practices seem to be related to small hospital size, rural location,
staffing shortages, and the lack … In contrast, research shows that some Safe Practices lack significant barriers to implementation. … Corrigan has written that one of the systemic problems with the current U.S. health care
system is the lack
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psnet.ahrq.gov/node/49473/psn-pdf
March 01, 2005 - Walking through a Series of Mishaps
First and foremost in this case, there was a fundamental lack of … of mistakes linked together—to remain intact.(3)
This type of miscommunication—or more accurately, lack … Overall, this lack of response and documentation in the face of important clinical changes can likely … This leads to greater challenges in catching the mistake, and the lack of
predictability makes it harder … Lack of predictability greatly
increases the risk of mistakes.
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psnet.ahrq.gov/node/49693/psn-pdf
October 01, 2013 - patients report lower satisfaction and are less
likely to continue to seek care at that setting.(2,3)
We lack … Transgender health raises a number of patient safety issues: lack of access to health care, increased … Lack of access to health care
Transgender populations experience specific challenges with the health … driver's
license or health insurance card) that indicate assigned rather than preferred gender, a lack … Lack of awareness about gender identity exacerbates family and
societal rejection and stigmatization
-
psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
March 21, 2009 - systematic review indicated that common barriers to prescribing naloxone in primary care settings include lack … Even though it is the legal duty of a pharmacist to provide patient counseling, limitations, including lack … of knowledge or clinical skills, lack of access to training programs, and lack of personnel or resources … caregivers in some circumstances. 8
Moreover, BPAs may cause alert fatigue, leading to errors or lack … as the requirement of co-prescribing naloxone are intended to improve public safety, policies that lack
-
psnet.ahrq.gov/node/854267/psn-pdf
October 04, 2023 - https://psnet.ahrq.gov/issue/why-admitting-mistakes-can-help-doctors-and-patients
The lack of a safety
-
psnet.ahrq.gov/node/60287/psn-pdf
April 29, 2020 - psnet.ahrq.gov/issue/inside-epidemic-misdiagnosed-women
Diagnosis in women is complicated by cultural norms, lack
-
psnet.ahrq.gov/node/60834/psn-pdf
September 01, 2020 - The piece highlights
systemic problems such as lack of transparency, investment in public health and
-
psnet.ahrq.gov/node/50680/psn-pdf
November 20, 2019 - This commentary argues the problem
rests with the lack of engagement of human factors engineering experts
-
psnet.ahrq.gov/node/50920/psn-pdf
February 19, 2020 - penalties, the data's ability to be effectively
applied across various types of institutions, and the lack
-
psnet.ahrq.gov/node/844772/psn-pdf
September 18, 2019 - article reports on the persistent
misdiagnosis and ineffective treatment of Lyme disease, including how lack
-
psnet.ahrq.gov/web-mm/falling-between-cracks-software
March 09, 2011 - The lack of interoperability between the office-based medical record platform and the inpatient system … systems or products without special effort on the part of the user.( 1 ) In the case described, the lack … Why might the health system described still lack interoperability between its inpatient and outpatient … While this reasoning may explain why a lack of interoperability resulted in this particular adverse drug … We lack interoperability across EHRs today because of myriad technical, policy, and cultural barriers
-
psnet.ahrq.gov/web-mm/saved-ecmo
May 05, 2017 - Whether this lack of planning was due to underappreciation of the severity of the patient’s disease, … lack of knowledge of the risks involved, or overconfidence in their own skills is unclear; however, it … The incidence of “high spinal” anesthesia varies in the literature and is largely unknown due to lack … for the Initiation of VA-ECMO
One of the biggest concerns in the management of this patient is the lack … November 30, 2021
WebM&M Cases
Lack of Sepsis Recognition
-
psnet.ahrq.gov/node/865597/psn-pdf
April 17, 2024 - patient-safety-and-mental-health-growing-quality-gap-canada
https://psnet.ahrq.gov/issue/staff-warned-about-lack-psychiatric-care-va-clinic-they-couldnt-prevent-tragedy
-
psnet.ahrq.gov/node/865493/psn-pdf
April 03, 2024 - implement-strategies-prevent-persistent-medication-errors-and-hazards-2024
Systemic failures can perpetuate unsafe care if a lack