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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/home
August 04, 2021 - Study
Barcode medication administration technology use in hospital practice: a mixed-methods
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psnet.ahrq.gov/issue/single-room-hospital-accommodation-associated-differences-healthcare-associated-infection
June 21, 2016 - Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience
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psnet.ahrq.gov/issue/emergency-physicians-views-direct-notification-laboratory-and-radiology-results-patients
March 23, 2012 - The results of this survey reveal the need for careful exploration of the best methods to increase patient
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psnet.ahrq.gov/issue/workarounds-hospital-electronic-prescribing-systems-qualitative-study-english-hospitals
December 21, 2022 - (s)
Electronic prescribing systems in hospitals to improve medication safety: a multi-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/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/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/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/web-mm/staggered-sensitivity-results
May 01, 2013 - While the procedures involved in reporting clinical microbiology laboratory results can create opportunities … Importantly, the patient in this case did not receive preoperative antibiotics prior to the surgical procedure … In these elective procedures, clindamycin is active against these pathogens and is an appropriate choice … Standard procedure calls for a clinical microbiology laboratory to provide an early report identifying … Polypharmacy
May 1, 2013
Systematic review of medication safety assessment methods
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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/node/865373/psn-pdf
March 27, 2024 - Balancing those becomes a very human
activity and often difficult to quantify with contemporary AI methods … It also led
us to look into different AI methods that could help with this puzzle, such as reinforcement … edn1
https://psnet.ahrq.gov//#_edn2
Another big challenge I see, especially with the more advanced methods … suggest looking at current strategies and practices for implementing new technologies, medications,
procedures
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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/perspective/what-makes-good-checklist
October 01, 2010 - For example, in one aviation checklist the emergency procedures covered a two-engine failure at altitude … The search method should be as well designed and thoroughly tested as the checklists. … Task analyses and observation of procedures can assist with this checklist requirement.
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
October 01, 2010 - For example, in one aviation checklist the emergency procedures covered a two-engine failure at altitude … The search method should be as well designed and thoroughly tested as the checklists. … Task analyses and observation of procedures can assist with this checklist requirement.
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psnet.ahrq.gov/periodic-issue/weekly-resource
February 26, 2025 - safety and team functionality at operative vaginal birth through multidisciplinary perspectives: a mixed methods … Review
Medication administration in aged care facilities: a mixed-methods systematic
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psnet.ahrq.gov/web-mm/falling-between-cracks-software
March 09, 2011 - Although traditional methods of information sharing (e.g., phone, fax, mail) across distinct health systems … are available for transmitting patients' medical information, such methods are error-prone, not secure
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psnet.ahrq.gov/node/863641/psn-pdf
February 28, 2024 - Research has found that active learning methods
(e.g., simulations, discussions) are more effective … for retaining information and supporting attitude and
behavioral changes than passive learning methods
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psnet.ahrq.gov/node/33600/psn-pdf
September 08, 2019 - each hospital likely has several preventable deaths per year, and a 2016 Annual Perspective
explores methods … matured, investigators have gained a better understanding of the underlying
causes of adverse events and methods