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Showing results for "learned".

5781. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34759/psn-pdf
      July 13, 2016 - Human Error. July 13, 2016 Reason JT. Cambridge, UK: Cambridge University Press; 1990. ISBN: 9780521306690. https://psnet.ahrq.gov/issue/human-error Despite writing almost nothing specifically on health care, clinical psychologist James Reason has influenced modern thinking about medical errors more than any other…

5782. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73992/psn-pdf
      October 20, 2021 - Mix-ups between the influenza (Flu) vaccine and COVID- 19 vaccines. October 20, 2021 ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4. https://psnet.ahrq.gov/issue/mix-ups-between-influenza-flu-vaccine-and-covid-19-vaccines Production pressure and low staff coverage can result in medica…

5783. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60990/psn-pdf
      October 07, 2020 - Tiered daily huddles: the power of teamwork in managing large healthcare organisations. October 7, 2020 Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ Qual Saf. 2020;29(12):1050-1052. doi:10.1136/bmjqs-2019-010575. https://psnet.ahrq.gov/issue/tiered-daily…

5784. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43588/psn-pdf
      January 21, 2015 - Resident Duty Hours Across Borders: An International Perspective. January 21, 2015 Imrie KR, Frank JR, Parshuram CS, eds. BMC Med Educ. 2014;14(suppl1):S1-S18. https://psnet.ahrq.gov/issue/resident-duty-hours-across-borders-international-perspective Articles in this special issue discuss the impact of resident dut…

5785. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838031/psn-pdf
      September 13, 2022 - Addressing the Loss of Trust in Safety Culture. September 7, 2022 Philadelphia, PA: Building Trust and the ABIM Foundation; September 13, 2022.  https://psnet.ahrq.gov/issue/addressing-loss-trust-safety-culture Trust in patient safety processes encourages reporting of concerns, learning from error, and develop…

5786. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73691/psn-pdf
      September 08, 2021 - Pump up the volume: tips for increasing error reporting and decreasing patient harm. September 8, 2021 ISMP Medication Safety Alert! Acute care edition. August 26, 2021;26(17);1-5.  https://psnet.ahrq.gov/issue/pump-volume-tips-increasing-error-reporting-and-decreasing-patient-harm Error reporting is an essen…

5787. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43672/psn-pdf
      November 12, 2014 - Is a tired doctor a safe doctor? November 12, 2014 Goldman B. "White Coat, Black Art." CBC Radio. October 31, 2014. https://psnet.ahrq.gov/issue/tired-doctor-safe-doctor This radio segment explores whether sleep deprivation affects the safety of care delivery. Panelists discuss sleep deprivation in health care, th…

5788. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60604/psn-pdf
      June 17, 2020 - The limits of current A.I. in health care: patient safety policing in hospitals. June 17, 2020 Furrow BR. NE Univ Law Rev. 2020;12(1):1-55. https://psnet.ahrq.gov/issue/limits-current-ai-health-care-patient-safety-policing-hospitals Artificial intelligence (AI) has the potential to improve the use of big data to e…

5789. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47585/psn-pdf
      December 05, 2018 - Insulin pumps have most reported problems in FDA database. December 5, 2018 Mohr H, Weiss M. Associated Press. November 27, 2018. https://psnet.ahrq.gov/issue/insulin-pumps-have-most-reported-problems-fda-database Usability issues, poor design, and lack of effective instruction hinder safe use of medical equipment…

5790. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846445/psn-pdf
      March 22, 2023 - Formalizing the hidden curriculum of performance enhancing errors. March 22, 2023 Kerray FM, Yule SJ, Tambyraja AL. Formalizing the hidden curriculum of performance enhancing errors. J Surg Educ. 2023;80(5):619-623. doi:10.1016/j.jsurg.2023.01.009. https://psnet.ahrq.gov/issue/formalizing-hidden-curriculum-perform…

5791. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838192/psn-pdf
      September 28, 2022 - When medical error becomes personal, activism becomes painful. September 28, 2022 Millenson M. Forbes. September 16, 2022. https://psnet.ahrq.gov/issue/when-medical-error-becomes-personal-activism-becomes-painful Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm w…

5792. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44074/psn-pdf
      November 16, 2015 - Investigating Clinical Incidents in the NHS. November 16, 2015 Sixth Report of Session 2014–15. House of Commons Public Administration Select Committee. London, England: The Stationery Office; March 27, 2015. Publication HC 886. https://psnet.ahrq.gov/issue/investigating-clinical-incidents-nhs Applying evidence ge…

5793. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34586/psn-pdf
      July 21, 2009 - Sentara Norfolk General Hospital: accelerating improvement by focusing on building a culture of safety. July 21, 2009 Yates GR, Hochman RF, Sayles SM, et al. Sentara Norfolk General Hospital: accelerating improvement by focusing on building a culture of safety. Jt Comm J Qual Patient Saf. 2004;30(10):534-542. http…

5794. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42635/psn-pdf
      December 06, 2013 - Improving disclosure and management of medical error—an opportunity to transform the surgeons of tomorrow. December 6, 2013 Tevlin R, Doherty E, Traynor O. Improving disclosure and management of medical error - an opportunity to transform the surgeons of tomorrow. Surgeon. 2013;11(6):338-43. doi:10.1016/j.surge.20…

5795. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851461/psn-pdf
      July 19, 2023 - Patient safety 2.0: slaying dragons, not just investigating them. July 19, 2023 Card AJ. Patient safety 2.0: slaying dragons, not just investigating them. J Patient Saf. 2023;19(6):394-395. doi:10.1097/pts.0000000000001140. https://psnet.ahrq.gov/issue/patient-safety-20-slaying-dragons-not-just-investigating-them …

5796. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34750/psn-pdf
      May 21, 2019 - The Basics of FMEA. 2nd ed. May 21, 2019 McDermott RE, Mikulak RJ, Beauregard MR. New York, NY: CRC Press; 2009. ISBN: 9781563273773. https://psnet.ahrq.gov/issue/basics-fmea-2nd-edition The authors provide a handbook that serves as the core tool for understanding and implementing the failure mode and effect analy…

5797. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866352/psn-pdf
      July 24, 2024 - Patient falls in the operating room: why is this still a problem in 2024? July 24, 2024 Pellegrino A, Brook K. Patient falls in the operating room: why is this still a problem in 2024? J Patient Saf. 2024;20(6):e87-e90. doi:10.1097/pts.0000000000001248. https://psnet.ahrq.gov/issue/patient-falls-operating-room-why…

5798. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838140/psn-pdf
      November 07, 2015 - Safety-I, Safety-II and resilience engineering. November 7, 2015 Patterson M, Deutsch ES. Safety-I, Safety-II and resilience engineering. Curr Probl Pediatr Adolesc Health Care. 2015;45(12):382-389. doi:10.1016/j.cppeds.2015.10.001. https://psnet.ahrq.gov/issue/safety-i-safety-ii-and-resilience-engineering Organiz…

5799. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44291/psn-pdf
      September 13, 2016 - A piece of my mind. I'm sorry. September 13, 2016 Kahn JS. A PIECE OF MY MIND. I'm Sorry. JAMA. 2015;313(24):2427-8. doi:10.1001/jama.2014.6507. https://psnet.ahrq.gov/issue/piece-my-mind-im-sorry Being accountable for errors and working to learn from them is key to improving patient safety. This commentary descri…

5800. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850938/psn-pdf
      June 21, 2023 - AI in medicine needs to be carefully deployed to counter bias – and not entrench it. June 21, 2023 Levi R, Gorenstein D. Health Shots. National Public Radio. June 6, 2023. https://psnet.ahrq.gov/issue/ai-medicine-needs-be-carefully-deployed-counter-bias-and-not-entrench-it Systemic biases are present in data …