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6821. Skin-deep diagnosis: affective bias and zebra retreat complicating the diagnosis of systemic sclerosis. | PSNet
      psnet.ahrq.gov/issue/skin-deep-diagnosis-affective-bias-and-zebra-retreat-complicating-diagnosis-systemic
      July 29, 2020 - Commentary Skin-deep diagnosis: affective bias and zebra retreat complicating the diagnosis of systemic sclerosis. Citation Text: Miller CS. Skin-deep diagnosis: affective bias and zebra retreat complicating the diagnosis of systemic sclerosis. Am J Med Sci. 2013;345(1):53-6. doi:10.1…

6822. Two decades since To Err Is Human: progress, but still a "chasm". | PSNet
      psnet.ahrq.gov/issue/two-decades-err-human-progress-still-chasm
      January 23, 2019 - Special or Theme Issue Two decades since To Err Is Human: progress, but still a "chasm". Citation Text: Dzau VJ, Shine KI. Two Decades Since To Err Is Human. JAMA. 2020;324(24):2489-2490. doi:10.1001/jama.2020.23151. Copy Citation Format: DOI Google Scholar BibTeX EndNote X…

6823. Communication failure: basic components, contributing factors, and the call for structure. | PSNet
      psnet.ahrq.gov/issue/communication-failure-basic-components-contributing-factors-and-call-structure
      March 04, 2011 - Commentary Communication failure: basic components, contributing factors, and the call for structure. Citation Text: Dayton E, Henriksen K. Communication failure: basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf. 2007;33(1):34-47. Copy Ci…

6824. One system's journey in creating a disclosure and apology program. | PSNet
      psnet.ahrq.gov/issue/one-systems-journey-creating-disclosure-and-apology-program
      May 27, 2011 - Commentary One system's journey in creating a disclosure and apology program. Citation Text: Peto RR, Tenerowicz LM, Benjamin EM, et al. One system's journey in creating a disclosure and apology program. Jt Comm J Qual Patient Saf. 2009;35(10):487-96. Copy Citation Format: …

6825. Pump up the volume: tips for increasing error reporting and decreasing patient harm. | PSNet
      psnet.ahrq.gov/issue/pump-volume-tips-increasing-error-reporting-and-decreasing-patient-harm
      January 27, 2021 - Newspaper/Magazine Article Pump up the volume: tips for increasing error reporting and decreasing patient harm. Citation Text: Pump up the volume: tips for increasing error reporting and decreasing patient harm. ISMP Medication Safety Alert! Acute care edition. August 26, 2021;26(17);1-5…

6826. Tolerance of uncertainty and the practice of emergency medicine. | PSNet
      psnet.ahrq.gov/issue/tolerance-uncertainty-and-practice-emergency-medicine
      May 25, 2022 - Commentary Tolerance of uncertainty and the practice of emergency medicine. Citation Text: Platts-Mills TF, Nagurney JM, Melnick ER. Tolerance of uncertainty and the practice of emergency medicine. Ann Emerg Med. 2020;75(6):715-720. doi:10.1016/j.annemergmed.2019.10.015. Copy Citation …

6827. Work-arounds in health care settings: literature review and research agenda. | PSNet
      psnet.ahrq.gov/issue/work-arounds-health-care-settings-literature-review-and-research-agenda
      October 02, 2013 - Review Work-arounds in health care settings: literature review and research agenda. Citation Text: Halbesleben JRB, Wakefield DS, Wakefield BJ. Work-arounds in health care settings: literature review and research agenda. Health Care Manage Rev. 2008;33(1):2-12. doi:10.1097/01.hmr.0000304…

6828. Inpatient Notes: mistakes in the hospital—communicating, apologizing, and beyond. | PSNet
      psnet.ahrq.gov/issue/inpatient-notes-mistakes-hospital-communicating-apologizing-and-beyond
      September 04, 2024 - Commentary Inpatient Notes: mistakes in the hospital—communicating, apologizing, and beyond. Citation Text: Kachalia A. Web Exclusives. Annals for Hospitalists Inpatient Notes - Mistakes in the Hospital-Communicating, Apologizing, and Beyond. Ann Intern Med. 2016;165(12):HO2-HO3. doi:10.…

6829. III. Hotline Implementation and Refinement | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/hotline/implement3.html
      May 01, 2016 - chemotherapy infusion, obstetrics departments, ambulatory surgery centers); inviting PFAC volunteers to learn

6830. E-Fetal-Monitoring Facguide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.docx
      May 01, 2017 - principles of patient safety derived from CUSP: · Standardize When Possible · Create Independent Checks · Learn

6831. Resident Physicians as Safety Champions | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/phys-championsgd/section5.html
      October 01, 2015 - addition to learning disease management and methods to optimize clinical outcomes, RPs are expected to learn

6832. Assess Patient Safety Culture Using the Hospital Survey on Patient Safety: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/cusp/assess-psc-hsop-slides.html
      February 01, 2017 - Assess Patient Safety Culture Using the Hospital Survey on Patient Safety: Slide Presentation AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients Assess Patient Safety Culture Using the Hospital Survey on Patient Safety Slide 2: Lear…

6833. Final Progress Report: Parent Perceptions of NICU Safety Culture: Parent-Centered Safety Culture Tool (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/etchegaray2-report.pdf
      January 01, 2024 - ability to protect my baby from harm and ensure that he/she is in a safe environment Learner: ability to learn

6834. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49722/psn-pdf
      December 01, 2014 - Medical Devices in the "Wild" December 1, 2014 Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/medical-devices-wild The Case A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes, chronic pain, arthritis, and…

6835. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50859/psn-pdf
      January 31, 2020 - In Conversation With... David Gruen, MD January 31, 2020 In Conversation With.. David Gruen, MD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-david-gruen-md Editor’s note: David R. Gruen, MD, MBA, FACR is the Chief Medical Officer, Imaging at IBM Watson Health and is a thought leader and…

6836. Rethinking Root Cause Analysis | PSNet
      psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
      August 21, 2016 - Summary In the early days of the patient safety movement, RCA seemed like an essential technique to learn

6837. Patient-Centered Outcomes Research Clinical Decision Support: Current State and Future Directions | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/patient-centered-outcomes-research-clinical-decision-support-current-state-and
      January 01, 2024 - Patient-Centered Outcomes Research Clinical Decision Support: Current State and Future Directions Project Description Publications Research Story Trust, interoperability, and ease of implementation are important factors that can increase uptake of evidence into prac…

6838. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848125/psn-pdf
      April 26, 2023 - Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units April 26, 2023 McGrath S, Blike G, Gale B, et al. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-…

6839. External-Stakeholder-Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pcor/external-stakeholder-report.pdf
      June 23, 2023 -  How can primary care in the United States learn from international models of success?

6840. Case 5. Heights Hospital | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case5.html
      November 01, 2014 - time) along with corporate executives visited Denver Health during the planning process to observe and learn … "The first year, people had to learn what the terminology was…the second year, we started to "rock and … At this conference, members of all hospitals were invited to learn about other projects and value stream … You learn the process. … Every time staff members participate in Lean, they learn more, and their expertise increases.