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psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
August 01, 2010 - Building a high reliability organization through a multi-method approach to monitoring the practice environment … How many times does the procedure have to be interrupted because the proceduralist doesn't have what … What is different in academic medicine is the opportunity to engage workers in process-improvement methods … and learn about them in a new way, how did you think through the benefits and downsides of different methods
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psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
March 10, 2021 - Sometimes that’s a council, and sometimes that’s another method of engagement. … of our clinicians and our administrators starting as far upstream in the development of policies and procedures … Maybe they’ve seen an issue in their infection control procedures. … with us as a strategy, but we're going to have to think really differently and creatively about the methods … the available process measures to assess more advanced nuances of an organization’s PFE policies and procedures
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psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
September 01, 2017 - We used both quantitative and qualitative methods, including multiple rapid assessment techniques such … fixing technical issues such as hardware or software issues but also clinical workflow, policies, and procedures … Users
The responsibility for designing, developing, paying for, and carrying out these policies, procedures … Rapid assessment of clinical information systems in the healthcare setting: an efficient method for time-pressed … Methods Inf Med. 2011;50:299-307. [go to PubMed]
5. Singh H, Thomas EJ, Sittig DF, et al.
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psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
August 01, 2006 - minor events that are harbingers of bigger problems); others through the thoughtful adoption of new procedures … (for instance, checkout of equipment before procedures, protocols for handoffs during relief of one … outcomes attributable to clearly preventable anesthesia causes in healthy patients undergoing elective procedures … March 29, 2023
Insurance claims for wrong-side, wrong-organ, wrong-procedure, or … June 15, 2011
Using a multi-method, user centred, prospective hazard analysis to assess
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.311_slideshow.ppt
December 01, 2013 - Measuring the anticoagulant effects of target specific oral anticoagulants—reasons, methods and current … dose of rivaroxaban).
12
Case: New Oral Anticoagulants (4)
Later when writing his note about the procedure … did not have any apparent bleeding and was discharged in good condition.
13
TSOACs and Invasive Procedures … There is especially little information about optimal management of TSOACs around the time of invasive procedures
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psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
April 12, 2023 - Additionally, although patients are often transferred to receive specific specialty care, such as a particular procedure … further understand which patients benefit most (and least) from transfer and why, and to understand best methods … Interhospital transfer and receipt of specialty procedures. J Hosp Med. 2018;13:383-387. … Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods
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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - This
procedure ensures that all aspects of the patient are considered: biological, psychological, and … In a national survey of physicians from specialties “for which evidence-
based mind-body methods could … issues."7 Even more concerning, approximately 1 in 3 physicians believed that integration of
these methods … Useful teaching methods include some that raise awareness and change attitudes (asking, promoting
reflection
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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - This procedure ensures that all aspects of the patient are
considered: biological, psychological, and … – In a national survey of physicians from specialties “for which evidence-
based mind-body methods … – Even more concerning, approximately 1 in 3 physicians believed that
integration of these methods … • Useful teaching methods include some that raise awareness and
change attitudes (asking, promoting
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psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-paramedics-provide-home
October 30, 2024 - program coordinator, communication channels for coordination between providers, standardized reporting procedures … , measures of progress, and methods for data collection
A protocol for scheduling home visits. … program coordinator, communication channels for coordination between providers, standardized reporting procedures … , measures of progress, and methods for data collection
A protocol for scheduling home visits.
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psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - Maybe you would only hear about it from a malpractice lawsuit—not the best method for learning. … I was trying to rely on my memory or yellow post-its, but those are unreliable methods.
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psnet.ahrq.gov/node/33861/psn-pdf
July 01, 2018 - Maybe you would only hear about it
from a malpractice lawsuit—not the best method for learning. … I was trying to rely on my memory or yellow post-its, but those are unreliable methods.
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - conditions from blood use within expected norms and incidental lysis of adhesions (both relatively trivial procedures … among physician-referred versus self-referred or primary care patients.( 6 ) Current risk adjustment methods … HCUP Methods Series Report No. 2006-01. … of the 1000 physicians or 5000 nurses to each do the right thing every time is probably the weakest method … 2011
A comparison of hospital adverse events identified by three widely used detection methods
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psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
March 07, 2012 - The delay in recognizing the post-procedure intraperitoneal hemorrhage led to a detailed review by the … managing patients following a liver biopsy were noted to be clearer in the outpatient setting where most procedures … widespread and easy-to-use imaging equipment, it has largely been replaced by one of the image-guided procedures … February 7, 2024
Application of human factors methods to understand missed follow-up … Hospitals
Health Care Providers
Quality and Safety Professionals
Internal Medicine
Bedside Procedures
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psnet.ahrq.gov/issue/changes-medication-safety-indicators-england-throughout-covid-19-pandemic-using-opensafely
October 19, 2022 - patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - CME activity which has been mitigated through UC Davis Health, Office of Continuing Medical Education procedures … To describe alternate methods of assessing patients for post-procedural pneumothorax without routine … 4,5 Provider experience has not been shown to correlate with risk of pneumothorax from bronchoscopic procedures … Stress, fatigue, and the complexity of various procedures can adversely affect our memories, and multi-tasking … Take-Home Points
Bronchoscopy is a safe, common procedure but, as with all procedures, complications
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - thoracentesis, the clinician lowered the right side-rail, but the side-rail was not raised after the procedure … during high-stakes clinical decision making: development and validation of a new behavioral observation method
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psnet.ahrq.gov/issue/patient-safety-engaging-medical-staff-toward-common-goal
September 08, 2021 - March 23, 2011
The Ethics of Using QI Methods to Improve Health Care Quality and Safety … June 9, 2010
Washington man's face catches fire during routine surgical procedure. … June 26, 2019
Wrong body part, wrong patient surgeries continue despite new procedures
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psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - on cardiac
POCUS.(17) In general, errors and pitfalls can occur with any acquired skill, with any procedure … He tolerated the procedure well, felt better, and requested to go
home. … He survived the procedure but had an extended course in
the intensive care unit. … psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
can determine which combination of assessment methods … These methods may include but are not limited to a question bank, a quality assurance
process, direct
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psnet.ahrq.gov/issue/biases-detection-apparent-weekend-effect-outcome-administrative-coding-data-population-based
September 23, 2020 - August 1, 2016
Harms from discharge to primary care: mixed methods analysis of incident
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psnet.ahrq.gov/issue/clinical-characteristics-and-short-term-outcomes-acute-kidney-injury-missed-diagnosis-older
April 20, 2022 - 2021
Potentially harmful medication dispenses after a fall or hip fracture: a mixed methods