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psnet.ahrq.gov/node/33746/psn-pdf
March 01, 2013 - In the IOM report, simulation was briefly mentioned as one of the strategies used in other industries … issue/err-human-building-safer-health-system
http://www.claytonchristensen.com/key-concepts/
RW: You mentioned
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psnet.ahrq.gov/node/33620/psn-pdf
September 01, 2005 - In response to “Getting to the Root of the Matter” (June
2005)
September 1, 2005
Grondin L, Saint S, Flanders S, et al. In response to “Getting to the Root of the Matter” (June 2005). PSNet
[internet]. 2005.
https://psnet.ahrq.gov/perspective/response-getting-root-matter-june-2005
In response to "Getting to the R…
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psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
June 29, 2020 - Finally, as I mentioned, the overall safety of the healthcare workforce helps to ensure they are able … NIH Guidelines As previously mentioned, the NIH has developed electronic guidelines intended to inform
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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - Sarah Mossburg: Earlier you talked about an action hierarchy and mentioned some weaker examples. … You mentioned earlier that RCA 2 is a toolkit and that there are pieces that people could pull and use … Sarah Mossburg: You mentioned that ambulatory and home health are starting to use RCAs.
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - Sarah Mossburg: Earlier you talked about an action hierarchy and mentioned some weaker examples. … You mentioned earlier that RCA 2 is a toolkit and that there are pieces that people could pull and use … Sarah Mossburg: You mentioned that ambulatory and home health are starting to use RCAs.
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psnet.ahrq.gov/issue/harnessing-event-report-data-identify-diagnostic-error-during-covid-19-pandemic
October 07, 2020 - Study
Harnessing event report data to identify diagnostic error during the COVID-19 pandemic.
Citation Text:
Shen L, Levie A, Singh H, et al. Harnessing event report data to identify diagnostic error during the COVID-19 pandemic. Jt Comm J Qual Patient Saf. 2022;48(2):71-80. doi:10.1016/…
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psnet.ahrq.gov/issue/role-knowledge-and-reasoning-processes-predictors-resident-physicians-susceptibility
March 18, 2020 - Study
Role of knowledge and reasoning processes as predictors of resident physicians' susceptibility to anchoring bias in diagnostic reasoning: a randomised controlled experiment.
Citation Text:
Mamede S, Zandbergen A, de Carvalho-Filho MA, et al. Role of knowledge and reasoning processe…
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psnet.ahrq.gov/node/60329/psn-pdf
May 14, 2020 - JW: Neal had mentioned that there are these pockets of interested parties that they were working with … your schedule frequently, I would make sure the technology works, I would create a
workflow like Neal mentioned
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psnet.ahrq.gov/node/60652/psn-pdf
June 29, 2020 - Finally, as I mentioned, the overall safety of the healthcare workforce helps to ensure they are able
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psnet.ahrq.gov/issue/toward-safer-health-care-system-critical-need-improve-measurement
November 03, 2015 - Commentary
Classic
Toward a safer health care system: the critical need to improve measurement.
Citation Text:
Jha AK, Pronovost P. Toward a Safer Health Care System: The Critical Need to Improve Measurement. JAMA. 2016;315(17):1831-2. doi:10.1001/jama.2016.3448…
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psnet.ahrq.gov/node/866217/psn-pdf
July 10, 2024 - Sarah Mossburg: Earlier, you mentioned the CMS Star Ratings program and publicly reported data.
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psnet.ahrq.gov/node/866847/psn-pdf
September 25, 2024 - Sarah Mossburg: You mentioned the importance of a culture of safety and organizational context, which
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psnet.ahrq.gov/node/33627/psn-pdf
February 01, 2006 - We have produced a 25-minute educational video that features the vignettes mentioned above and
describes
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psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic
June 29, 2020 - NIH Guidelines As previously mentioned, the NIH has developed electronic guidelines intended to inform … Finally, as I mentioned, the overall safety of the healthcare workforce helps to ensure they are able
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psnet.ahrq.gov/issue/performance-trigger-tool-detecting-drug-related-hospital-admissions-older-people-analysis
December 21, 2022 - Study
Performance of a trigger tool for detecting drug-related hospital admissions in older people: analysis from the OPERAM trial.
Citation Text:
Zerah L, Henrard S, Thevelin S, et al. Performance of a trigger tool for detecting drug-related hospital admissions in older people: analysis…
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psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
February 21, 2020 - Interestingly, in the study of EHR-generated alerts for abnormal laboratory results mentioned above,
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psnet.ahrq.gov/web-mm/sick-and-pregnant
August 25, 2021 - admitting nurse received a report from the ED nurse, but again, the patient's pregnancy status was not mentioned
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psnet.ahrq.gov/node/74149/psn-pdf
January 07, 2022 - He mentioned that two days prior, he
had been up all-night sending texts to a girl and felt “manic,” … Although there insufficient evidence to recommend any one
tool,11 several mentioned by the Joint Commission
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psnet.ahrq.gov/node/73398/psn-pdf
June 30, 2021 - WHO [World
Health Organization] and CDC [Centers for Disease Control and Prevention] documents had mentioned … alternative care sites, but they mentioned them just in the practical nature of bed surge capacity.
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psnet.ahrq.gov/node/49537/psn-pdf
June 01, 2007 - If we apply the recommendations
of the above mentioned systematic review (7), he would also receive