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Showing results for "learned".

4441. Involuntary automaticity: a work-system induced risk to safe health care. | PSNet
      psnet.ahrq.gov/issue/involuntary-automaticity-work-system-induced-risk-safe-health-care
      June 22, 2009 - Commentary Involuntary automaticity: a work-system induced risk to safe health care. Citation Text: Toft B, Mascie-Taylor H. Involuntary automaticity: a work-system induced risk to safe health care. Health Serv Manage Res. 2005;18(4):211-6. Copy Citation Format: Google Sc…

4442. Sleep, science, and policy change. | PSNet
      psnet.ahrq.gov/issue/sleep-science-and-policy-change
      September 21, 2022 - Commentary Sleep, science, and policy change. Citation Text: Wylie D. Sleep, science, and policy change. N Engl J Med. 2005;352(2):196-7. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citatio…

4443. 11 medicine mistakes to avoid. | PSNet
      psnet.ahrq.gov/issue/11-medicine-mistakes-avoid
      March 20, 2024 - Newspaper/Magazine Article 11 medicine mistakes to avoid. Citation Text: Crouch M. 11 medicine mistakes to avoid. AARP. August 06, 2024; Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation …

4444. Audit of handover in an ENT unit. | PSNet
      psnet.ahrq.gov/issue/audit-handover-ent-unit
      October 28, 2020 - Study Audit of handover in an ENT unit. Citation Text: Ellul D, Robson AK. Audit of handover in an ENT unit. J Laryngol Otol. 2011;125(9):924-7. doi:10.1017/S0022215111000880. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…

4445. A piece of my mind. Changing the narrative. | PSNet
      psnet.ahrq.gov/issue/piece-my-mind-changing-narrative
      December 13, 2023 - Commentary A piece of my mind. Changing the narrative. Citation Text: Allen-Dicker J. Changing the Narrative. JAMA. 2016;316(3). doi:10.1001/jama.2016.3029. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Do…

4446. Kenneth W. Kizer, MD, MPH: health care quality evangelist. | PSNet
      psnet.ahrq.gov/issue/kenneth-w-kizer-md-mph-health-care-quality-evangelist
      July 28, 2014 - Commentary Kenneth W. Kizer, MD, MPH: health care quality evangelist. Citation Text: Kizer KW. Kenneth W. Kizer, MD, MPH: health care quality evangelist. Interview by Brian Vastag. JAMA. 2001;285(7):869-71. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML E…

4447. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38247/psn-pdf
      June 27, 2018 - Debriefing for patient safety. June 27, 2018 Turner SH, Kurtz WD. Patient Saf Qual Healthc. November/December 2008:5:42-44,46. https://psnet.ahrq.gov/issue/debriefing-patient-safety This article provides guidelines for effective clinical debriefings and suggests how to position these conversations as learning oppo…

4448. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37250/psn-pdf
      October 10, 2007 - Why worry about near misses? October 10, 2007 Marella WM. https://psnet.ahrq.gov/issue/why-worry-about-near-misses The author describes the collection and management of information on near misses as well as using such data to support learning opportunities for hospital staffs. https://psnet.ahrq.gov/issue/why-wor…

4449. The Submit a Case Process | PSNet
      psnet.ahrq.gov/submit-case
      November 03, 2025 - The Submit a Case Process PSNet’s Submit a Case feature allows health care professionals to submit de-identified cases that feature patient safety and health care quality issues to PSNet’s WebM&M educational journal. Watch the video below to learn more about the Submit a Case process. Submit Your Case   …

4450. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33847/psn-pdf
      August 01, 2017 - drawing and trying to explain their point of how they would do this differently or some other trick they learned

4451. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33632/psn-pdf
      April 01, 2006 - Can you share some of the lessons that you have learned through your work that are relevant to other

4452. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36356/psn-pdf
      June 16, 2019 - ISMP medication error report analysis. June 16, 2019 Cohen MR. https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-8 This monthly column discusses the value of learning from rare yet severe events, shares successes with read backs, and reports on errors involving non-formulary medications and vincri…

4453. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40135/psn-pdf
      October 03, 2017 - A pinpoint beam strays invisibly, harming instead of healing. October 3, 2017 Bogdanich W; Rebelo K. https://psnet.ahrq.gov/issue/pinpoint-beam-strays-invisibly-harming-instead-healing This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learnin…

4454. Never Events | PSNet
      psnet.ahrq.gov/primer/never-events
      June 15, 2024 - Never Events Citation Text: Never Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cita…

4455. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.131_slideshow.ppt
      August 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case August 2006 Physical Diagnosis: A Lost Art? Source and Credits This presentation is based on the August 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: George Thompson III,…

4456. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33780/psn-pdf
      July 01, 2015 - Safety and Medical Education January 1, 2014 Ranji SR. Safety and Medical Education. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/safety-and-medical-education Annual Perspective 2014 As the patient safety field has grown, so too has the appreciation for the need to improve safety in medical educatio…

4457. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863641/psn-pdf
      February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training February 28, 2024 Haugstetter M, Hines S, Sousane Z, et al. Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork…

4458. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38916/psn-pdf
      July 03, 2013 - Patient Safety Papers 4. July 3, 2013 Baker GR, ed. Healthc Q. 2009;12(Spec No Patient):1-198.   https://psnet.ahrq.gov/issue/patient-safety-papers-4 This special issue discusses Canadian patient safety efforts in identifying risks, designing safe systems, implementing solutions, developing learning systems, …

4459. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42549/psn-pdf
      August 28, 2013 - Patient safety: threats and solutions. August 28, 2013 McCaughan D, Kaufman G. Patient safety: threats and solutions. Nurs Stand. 2013;27(44):48-55; quiz 56, 58. https://psnet.ahrq.gov/issue/patient-safety-threats-and-solutions This commentary provides an overview of patient safety, including types of adverse even…

4460. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42162/psn-pdf
      December 06, 2016 - The robot will see you now. December 6, 2016 Cohn J. The Atlantic. March 2013;311:59–67. https://psnet.ahrq.gov/issue/robot-will-see-you-now This magazine article reports how technology, such as IBM's Watson, can improve the efficiency and accuracy of health care decision making. https://psnet.ahrq.gov/issue/robo…