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Just culture: who gets to draw the line? | PSNet

psnet.ahrq.gov/issue/just-culture-who-gets-draw-line

June 24, 2020 - December 9, 2014 Laparoscopic bile duct injury: understanding the psychology and heuristics … December 15, 2011 Criminalization of medical error: who draws the line?

When doctors make mistakes. | PSNet

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September 28, 2017 - Gawande uses a harrowing personal example of a medical error to illustrate that medical mistakes are … Gawande attacks the current medical malpractice system, stating that it creates an environment of silence … He describes the current forum used by physicians to process medical errors, the Morbidity and Mortality … July 3, 2013 Family of woman who died after a medical error joins hospital's safety panel … ; The impact of missed abdominal injuries in the era of nonoperative management.

Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. | PSNet

psnet.ahrq.gov/issue/missed-and-delayed-diagnoses-emergency-department-study-closed-malpractice-claims-4-liability

March 02, 2011 - March 2, 2011 Claims, errors, and compensation payments in medical malpractice litigation … March 13, 2019 Who pays for medical errors? … An analysis of adverse event costs, the medical liability system, and incentives for patient safety improvement … April 26, 2023 Factors associated with diagnostic error: an analysis of closed medical … July 14, 2018 Surgeon commitment to trauma care decreases missed injuries.

Strength of safety measures introduced by medical practices to prevent a recurrence of patient safety incidents: an observational study. | PSNet

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May 01, 2024 - Study Strength of safety measures introduced by medical practices to prevent a recurrence … Strength of safety measures introduced by medical practices to prevent a recurrence of patient safety … Strength of safety measures introduced by medical practices to prevent a recurrence of patient safety … Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries

Liability claims and costs before and after implementation of a medical error disclosure program. | PSNet

psnet.ahrq.gov/issue/liability-claims-and-costs-and-after-implementation-medical-error-disclosure-program

April 24, 2018 - Classic Liability claims and costs before and after implementation of a medical … Liability claims and costs before and after implementation of a medical error disclosure program. … lawsuits by encouraging more open provider–patient communication and more fairly compensating patients for injuries … Liability claims and costs before and after implementation of a medical error disclosure program. … February 17, 2011 Medical errors: should you apologize?

Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation | PSNet

psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation

June 28, 2023 - apparently due to miscommunication at change-of-shift, led to more serious consequences from his iatrogenic injury … facial or skull base fractures; head, neck, or esophageal neoplasms; recent upper GI surgery; esophageal trauma … device-related pressure injuries in the intensive care unit showed that 1.6% were caused by NGTs. 13 … Each attempt at NGT placement presents a risk of complications such as esophageal trauma, tracheal placement … Nursing care guidelines for reducing hospital-acquired nasogastric tube-related pressure injuries.

Radiation offers new cures, and ways to do harm. | PSNet

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January 20, 2010 - First in a series on medical radiation, this news feature investigates patient deaths and injuries following … August 20, 2021 FDA to end program that hid millions of reports on faulty medical devices … View More See More About The Topic General Hospitals Patients Medical

Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. | PSNet

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January 09, 2019 - provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury … February 11, 2015 Physician-Owned Specialty Hospital's Ability to Manage Medical Emergencies

The presence and potential impact of psychological safety in the healthcare setting: an evidence synthesis. | PSNet

psnet.ahrq.gov/issue/presence-and-potential-impact-psychological-safety-healthcare-setting-evidence-synthesis

October 20, 2021 - Health care workers' experiences of workplace incidents that posed a risk of patient and worker injury … September 14, 2022 Toward constructive change after making a medical error: recovery … January 19, 2022 Hierarchy and medical error: speaking up when witnessing an error.

Increases in drug and opioid overdose deaths—United States, 2000–2015. | PSNet

psnet.ahrq.gov/issue/increases-drug-and-opioid-overdose-deaths-united-states-2000-2015

January 23, 2019 - July 14, 2021 Improving teamwork on general medical units: when teams do not work face-to-face … August 1, 2016 A controlled trial of a rapid response system in an academic medical center … May 16, 2012 Assessing the National Electronic Injury Surveillance System—Cooperative

Hospital-acquired Conditions Reduction Program, patient safety, and Magnet designation in the United States. | PSNet

psnet.ahrq.gov/issue/hospital-acquired-conditions-reduction-program-patient-safety-and-magnet-designation-united

October 09, 2019 - Validity of 16 AHRQ Patient Safety Indicators to identify in-hospital complications: a medical … August 10, 2022 Complexity bias in the prevention of iatrogenic injury: why specific … About The Topic Hospitals Nurse Managers Quality and Safety Professionals Nurse Care Medical

Vital signs: improving antibiotic use among hospitalized patients. | PSNet

psnet.ahrq.gov/issue/vital-signs-improving-antibiotic-use-among-hospitalized-patients

February 27, 2019 - June 12, 2013 Assessing the National Electronic Injury Surveillance System—Cooperative … urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical … October 4, 2013 As she lay dying: how I fought to stop medical errors from killing my

2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents from the nation’s largest event reporting database. | PSNet

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July 06, 2022 - October 6, 2021 Reporting incidents involving the use of advanced medical technologies … 2023 Development and interrater agreement of a novel classification system combining medical … January 19, 2022 Communication failures contributing to patient injury in anaesthesia

Patient handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs. | PSNet

psnet.ahrq.gov/issue/patient-handoffs-and-multi-specialty-trainee-perspectives-across-institution-informing

February 23, 2022 - Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical … The effects of leadership curricula with and without implicit bias training on graduate medical … March 14, 2012 Patterns of communication breakdowns resulting in injury to surgical patients

The wicked problem of patient misidentification: how could the technological revolution help address patient safety? | PSNet

psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution-help-address

July 10, 2024 - 27, 2016 Towards international consensus on patient harm: perspectives on pressure injury … August 7, 2019 Medical device-related pressure ulcers: a systematic review and meta-analysis

Do Me a Favor | PSNet

psnet.ahrq.gov/web-mm/do-me-favor

September 12, 2016 - At some point, most of us have been asked to help a colleague, friend, or family member with a medical … In this case, the resident may not have been fully competent to perform the exam (resulting in injury … Additionally, failing to include nursing in procedures exposes patients to risks of injury related to … American Medical Association Web site. Available at: [ go to related site ]. … history Reluctance to obtain or submit to a complete medical examination Diagnosis

Medication safety systems and the important role of pharmacists. | PSNet

psnet.ahrq.gov/issue/medication-safety-systems-and-important-role-pharmacists

July 19, 2023 - January 6, 2018 Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy … View More Related Resources Making polypharmacy safer for children with medical … March 27, 2013 Clinical pharmacists and inpatient medical care: a systematic review.

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