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psnet.ahrq.gov/issue/rate-diagnostic-errors-and-serious-misdiagnosis-related-harms-major-vascular-events
July 28, 2023 - in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method … specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods … in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method
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psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - • During the procedure, the abdominal wall transilluminated as expected, and
1-to-1 gastric motion … Completion of the PEG tube procedure. … sites use
proactive review (double interpretation by separate radiologists) in addition to
reactive methods … utilizing the malpositioned tube. 4,10,11,14,25
27
PEG Tube Complications (6)
There are several methods … A simple and inexpensive method of removal or replacement of gastrostomy tubes.
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psnet.ahrq.gov/issue/negative-emotions-experienced-healthcare-staff-following-medication-administration-errors
December 18, 2019 - Using qualitative methods and text mining of medication error incident reports, researchers in this study … analysis of medication administration errors using incident reports, the Global Trigger Tool method, … February 15, 2023
Toward the translation of systems thinking methods in patient safety … July 29, 2020
Differences between methods of detecting medication errors: a secondary … analysis of medication administration errors using incident reports, the Global Trigger Tool method,
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psnet.ahrq.gov/issue/what-causes-adverse-events-prehospital-care-human-factors-approach
July 26, 2023 - Factors influencing medication errors in the prehospital paramedic environment: a mixed method … 2019
Medication safety in emergency medical services: approaching an evidence-based method
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psnet.ahrq.gov/issue/evaluation-critical-incidents-general-surgery
April 29, 2009 - Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method … , 2014
Assessing distractors and teamwork during surgery: developing an event-based method … Optimising surgical training: use of feedback to reduce errors during a simulated surgical procedure
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psnet.ahrq.gov/issue/obstacles-research-effects-interruptions-healthcare
April 19, 2017 - commentary suggests that research about interruptions clearly determine definitions, data collection methods … Related Resources From the Same Author(s)
Two sides to every story: the Dual Perspectives Method … September 27, 2017
Two sides to every story: the Dual Perspectives Method for examining
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psnet.ahrq.gov/issue/examining-causes-and-prevention-strategies-adverse-events-deceased-hospital-patients
June 08, 2022 - Root cause analysis using the prevention and recovery information system for monitoring and analysis method … October 6, 2021
A systematic review of methods for medical record analysis to detect … Monitoring preventable adverse events and near misses: number and type identified differ depending on method
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psnet.ahrq.gov/issue/e-delphi-study-obtain-expert-consensus-level-risk-associated-preventable-e-prescribing-events
January 19, 2022 - 2021
Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method … discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method … 2023
Electronic prescribing systems in hospitals to improve medication safety: a multi-methods
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psnet.ahrq.gov/issue/patient-safety-monitoring-acute-care-decentralized-national-health-care-system-conceptual
July 27, 2022 - Root cause analysis using the prevention and recovery information system for monitoring and analysis method … November 10, 2021
Medication safety in mental health hospitals: a mixed-methods analysis … Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method
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psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - delays in diagnosing malignancies or other conditions warranting urgent
interventions such as surgical procedures … Newer electronic methods can also be used to help ensure effective
communication at the systems level … Although this
safeguard is a one-way method of communication, the communication loop could be closed … Secure text messaging platforms offer another e-method that can be used by radiologists to
communicate … Improving communication by implementing multiple systems-based changes, using both e-methods
and more
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psnet.ahrq.gov/issue/right-medication-right-dose-right-patient-right-time-and-right-route-how-do-we-select-right
March 02, 2016 - Resources From the Same Author(s)
Seniors managing multiple medications: using mixed methods … Client, caregiver, and provider perspectives of safety in palliative home care: a mixed method … December 4, 2016
The use of human factors methods to identify and mitigate safety issues … March 13, 2019
Formative evaluation of the video reflexive ethnography method, as applied
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psnet.ahrq.gov/issue/reclaiming-systems-approach-paediatric-safety
April 03, 2019 - Development of an electronic pediatric all-cause harm measurement tool using a modified Delphi method … November 28, 2018
The trigger tool as a method to measure harmful medication errors in
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psnet.ahrq.gov/issue/information-chaos-primary-care-implications-physician-performance-and-patient-safety
July 02, 2019 - Prescribers' interactions with medication alerts at the point of prescribing: a multi-method … March 11, 2011
A mixed method study of the merits of e-prescribing drug alerts in primary
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psnet.ahrq.gov/issue/building-social-capital-healthcare-organizations-thinking-ecologically-safer-care
June 23, 2009 - June 23, 2009
Seniors managing multiple medications: using mixed methods to view the … July 23, 2008
Medication administration technologies and patient safety: a mixed-method … March 13, 2019
Formative evaluation of the video reflexive ethnography method, as applied
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psnet.ahrq.gov/issue/assessing-impact-new-pediatric-healthcare-facility-medication-administration-human-factors
February 07, 2024 - A qualitative study using the framework method of analysis. … A mixed method study.
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psnet.ahrq.gov/issue/experience-feedback-committees-way-implementing-root-cause-analysis-practice-hospital-medical
October 30, 2024 - July 31, 2024
Mitigating imperfect data validity in administrative data PSIs: a method … , 2011
View More
Related Resources
Using the Generic Analysis Method
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psnet.ahrq.gov/node/35176/psn-pdf
June 23, 2009 - These included reduced
mortality after elective procedures, fewer adverse events attributed to deaths … The
authors conclude that continuous peer review offers an important and cost-effective method for improving
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psnet.ahrq.gov/node/866351/psn-pdf
July 24, 2024 - all the SEIPS components and resilience capacities
(e.g., preparedness, adaptation), indicating this method … can be used to complement traditional investigative
methods.
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psnet.ahrq.gov/issue/adverse-events-neonatal-intensive-care-unit-development-testing-and-findings-nicu-focused
April 11, 2011 - The trigger tool appeared to be a sensitive (though nonspecific) method for identifying AEs. … Development of an electronic pediatric all-cause harm measurement tool using a modified Delphi method
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psnet.ahrq.gov/issue/causes-their-death-appear-unto-our-shame-perpetual-why-root-cause-analysis-not-best-model
September 27, 2016 - While the authors assert that the method may not be helpful, their findings also emphasize the importance … April 3, 2024
Two sides to every story: the Dual Perspectives Method for examining interruptions