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psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
March 01, 2015 - 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods
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psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
February 01, 2019 - Compliance with and barriers to implementing the surgical safety checklist: a mixed-methods
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psnet.ahrq.gov/node/49646/psn-pdf
February 01, 2012 - A comparison of methods to
communicate treatment preferences in nursing facilities: traditional practices
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psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
August 04, 2021 - The patient never saw her new physicians and was never scheduled for the recommended cardiac surgery procedure … She did undergo the procedure without complications and proceeded to have a healthy child at full term … Current methods of transfer of young people with Type 1 diabetes to adult services.
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psnet.ahrq.gov/periodic-issue/periodic-issue-297
June 30, 2021 - Book/Report
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings … The authors recommend that the NHS use human factors methods to design control processes to target and
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - The patient
had two procedures during the previous week - an arteriogram followed by balloon tamponade … Methods such as continuous oximetry, end-tidal carbon dioxide (ETCO2)
monitoring, and acoustic respiratory
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psnet.ahrq.gov/node/865412/psn-pdf
March 27, 2024 - activity which has been mitigated through UC Davis Health, Office of Continuing Medical
Education procedures … failure-follow-test-results-ambulatory-patients-systematic-review
https://psnet.ahrq.gov/issue/application-human-factors-methods-understand-missed-follow-abnormal-test-results
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psnet.ahrq.gov/node/33611/psn-pdf
July 01, 2005 - Instead, anything detected by direct observation or by our other study methods was presented to
two
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Handoffs and Transitions
January 22, 2014
Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical integration, the United States health care system remains highly
fragmented. From it…
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psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
March 15, 2023 - technology to improve clinical care such as RPM or using augmented reality for remote support during bedside procedures … At times, patients will want to please their health care provider, and with the pen and paper method
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psnet.ahrq.gov/perspective/remote-patient-monitoring
March 15, 2023 - technology to improve clinical care such as RPM or using augmented reality for remote support during bedside procedures … At times, patients will want to please their health care provider, and with the pen and paper method
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psnet.ahrq.gov/node/33740/psn-pdf
November 01, 2012 - I
would be the first to say that the routine annual physical, for example, is a low-yield procedure. … in with a very specific symptom and being hospitalized, the physical exam is a fairly high-
yield procedure … But, it's clearly not a one-way street where we are showing them only old-
fashioned methods.
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psnet.ahrq.gov/node/843051/psn-pdf
February 01, 2023 - activity which has been mitigated through UC Davis Health, Office of Continuing Medical
Education procedures … goiter, Graves’ disease, and chronic lymphocytic thyroiditis; and (3) process-of-care factors such
as procedure … Such training includes regular review of airway algorithms,
methods for airway support and ventilation
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psnet.ahrq.gov/node/33663/psn-pdf
September 15, 2008 - We set a goal to create CPOE content for 80% of
our admission diagnosis/procedures and for the majority
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
January 01, 2022 - been historically underappreciated for many
reasons – the data are limited, there are few reliable methods … – The most common system-related problems were due to poor policies,
processes, procedures, teamwork
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psnet.ahrq.gov/node/49519/psn-pdf
September 01, 2006 - Many of these errors are caught before harm reaches the patient, as practitioners have a variety of
methods … diagnosis, updated medications and problem list, current baseline
status (eg, cardiac status), and recent procedures
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psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
June 01, 2011 - Scott Snook calls "practical drift"—that is that organizations can start to deviate from established procedures … In some cases, the patients themselves might be interested in procedures or medications that might increase … surgical team placed an anesthetized patient onto a modular table during preparations for a spinal procedure … Human Factors Methods for Design: Making Systems Human-Centered. Boca Raton, FL: CRC Press; 2004.
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psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
December 01, 2014 - will need to be further refined to ensure a clear blending of improvement science and sociological methods … We've looked at quality and quality information methods, focusing on safety, and then talking about value
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psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
August 14, 2024 - CME activity which has been mitigated through UC Davis Health, Office of Continuing Medical Education procedures … goiter, Graves’ disease, and chronic lymphocytic thyroiditis; and (3) process-of-care factors such as procedure … Such training includes regular review of airway algorithms, methods for airway support and ventilation
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - The absence of a foreign body was documented in the procedure note but not whether the tendon was visualized … Clinical Procedures in Emergency Medicine . 7th ed. Saunders Elsevier; 2019:956-979. … Flexor tendon repair: recent changes and current methods.