-
psnet.ahrq.gov/node/43001/psn-pdf
March 19, 2014 - These methods produced
varying rates of hospital mortality, and classification of hospitals as either … higher or lower than average
differed depending on the estimation method.
-
psnet.ahrq.gov/node/45138/psn-pdf
May 25, 2016 - This quality improvement
project describes the use of plan-do-study-act methods to develop and revise … weekend-effect-pediatric-surgery-increased-mortality-children-undergoing-urgent-surgery
https://psnet.ahrq.gov/issue/systematic-review-application-plan-do-study-act-method-improve-quality-healthcare
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psnet.ahrq.gov/node/39932/psn-pdf
October 20, 2010 - patient after surgery has traditionally relied on
nurses manually counting instruments used during the procedure … However, this method is not foolproof,
and this qualitative study used interviews with operating room
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psnet.ahrq.gov/node/37772/psn-pdf
May 21, 2008 - used to analyze errors in anesthesia and
summarizes several initiatives that use this investigation method
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psnet.ahrq.gov/node/39883/psn-pdf
August 22, 2011 - Leadership method helps executives answer the
"hows" in patient safety initiatives.
-
psnet.ahrq.gov/node/41869/psn-pdf
November 28, 2012 - /issue/tracking-intraoperative-complications
This cohort study found that a prospective, real-time method
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
May 01, 2009 - State the key diagnostic differences between delirium and dementia
Describe the Confusion Assessment Method … Confusion Assessment Method
Diagnosis of delirium requires features 1 and 2, and either 3 or 4
See … Clarifying confusion: the confusion assessment method. A new method for detection of delirium.
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psnet.ahrq.gov/node/34995/psn-pdf
February 03, 2011 - research-adverse-drug-events-and-reports-radar-project
This article summarizes the structure, funding, organization, and methods … authors conclude by sharing potential implications of the
program’s efforts and how this surveillance method
-
psnet.ahrq.gov/node/36680/psn-pdf
July 10, 2008 - identifying-diagnostic-errors-primary-care-using-electronic-screening-algorithm
This study used a novel screening method … A prior study used comparable methods to identify a strikingly similar
incidence of missed diagnosis
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psnet.ahrq.gov/node/46116/psn-pdf
May 24, 2017 - estimates and applied storytelling, Lean Six Sigma, and Fishbone
diagram approaches to develop and test a method … elimination-emergency-department-medication-errors-due-estimated-weights
https://psnet.ahrq.gov/issue/pediatric-prehospital-medication-dosing-errors-mixed-methods-study
-
psnet.ahrq.gov/node/36528/psn-pdf
January 20, 2010 - creating-high-reliability-health-care-organizations
High-reliability organizations (eg, the aviation industry) have developed methods … The framework is based on a previously published method for
evaluating safety interventions; the key
-
psnet.ahrq.gov/node/44165/psn-pdf
May 27, 2015 - psnet.ahrq.gov/issue/unplanned-return-theater-quality-care-and-risk-management-index
Trigger tools are a useful method … researchers examined a retrospective case series of orthopedic and trauma surgeries in which a
revision procedure
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psnet.ahrq.gov/node/35432/psn-pdf
September 11, 2009 - psnet.ahrq.gov/issue/improving-patient-safety-moving-beyond-hype-medical-errors
The authors advocate for a method
-
psnet.ahrq.gov/node/41179/psn-pdf
February 29, 2012 - //psnet.ahrq.gov/issue/high-fidelity-simulation-research-tool
This review explores simulation as a method
-
psnet.ahrq.gov/issue/missed-diagnoses-acute-myocardial-infarction-emergency-department-variation-patient-and
April 08, 2018 - 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
-
psnet.ahrq.gov/node/38921/psn-pdf
September 09, 2009 - using-medical-emergency-teams-detect-preventable-adverse-events
Structured analysis of medical emergency team calls proved to be an effective method
-
psnet.ahrq.gov/node/49550/psn-pdf
December 01, 2007 - death is unexpected.(3)
Though less emotionally charged, many other Diagnostic Related Groups (DRGs [a method … This is a far more efficient method of
identifying potential safety problems than most other methods … The efficiency of the ascertainment method and the rate of false positives represent just two characteristics … Technical Specifications
Death in low-
mortality DRGs
Mortality rate for admitting
diagnoses or procedures … Conduciveness to
change
The detection method should capture sufficient detail to understand the events
-
psnet.ahrq.gov/node/38130/psn-pdf
January 02, 2017 - psnet.ahrq.gov/issue/view-world-through-different-lens-shadowing-another-provider
This article summarizes the method
-
psnet.ahrq.gov/node/42388/psn-pdf
June 26, 2013 - independent-double-checks-undervalued-and-misused
Noting inconsistent evidence for independent double checks as a method
-
psnet.ahrq.gov/node/37718/psn-pdf
April 23, 2008 - https://psnet.ahrq.gov/issue/mistakes-and-disclosure
This article describes a method for teaching residents