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Showing results for "mistakes".

  1. Developing, implementing, evaluating electronic apparent cause analysis across a health care system. | PSNet

    psnet.ahrq.gov/issue/developing-implementing-evaluating-electronic-apparent-cause-analysis-across-health-care
    February 07, 2018 - Study Developing, implementing, evaluating electronic apparent cause analysis across a health care system. Citation Text: Oster CA, Woods E, Mumma J, et al. Developing, implementing, evaluating electronic apparent cause analysis across a health care system. Jt Comm J Qual Patient Saf. 2…

  2. When clinicians drop out and start over after adverse events. | PSNet

    psnet.ahrq.gov/issue/when-clinicians-drop-out-and-start-over-after-adverse-events
    May 18, 2022 - Study When clinicians drop out and start over after adverse events. Citation Text: Rodriquez J, Scott SD. When Clinicians Drop Out and Start Over after Adverse Events. Jt Comm J Qual Patient Saf. 2018;44(3):137-145. doi:10.1016/j.jcjq.2017.08.008. Copy Citation Format: DOI …

  3. The combined effect of psychological and social capital in registered nurses experiencing second victimization: a structural equation model. | PSNet

    psnet.ahrq.gov/issue/combined-effect-psychological-and-social-capital-registered-nurses-experiencing-second
    December 15, 2021 - Study The combined effect of psychological and social capital in registered nurses experiencing second victimization: a structural equation model. Citation Text: Hinkley T‐L. The combined effect of psychological and social capital in registered nurses experiencing second victimization: a…

  4. False dawns and new horizons in patient safety research and practice. | PSNet

    psnet.ahrq.gov/issue/false-dawns-and-new-horizons-patient-safety-research-and-practice
    July 24, 2024 - Commentary False dawns and new horizons in patient safety research and practice. Citation Text: Mannion R, Braithwaite J. False Dawns and New Horizons in Patient Safety Research and Practice. Int J Health Policy Manag. 2017;6(12). doi:10.15171/ijhpm.2017.115. Copy Citation Format: …

  5. The dichotomy of the application of a systems approach in UK healthcare the challenges and priorities for implementation. | PSNet

    psnet.ahrq.gov/issue/dichotomy-application-systems-approach-uk-healthcare-challenges-and-priorities-implementation
    January 09, 2018 - Commentary The dichotomy of the application of a systems approach in UK healthcare the challenges and priorities for implementation. Citation Text: Pickup L, Lang A, Atkinson S, et al. The dichotomy of the application of a systems approach in UK healthcare the challenges and priorities f…

  6. Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach. | PSNet

    psnet.ahrq.gov/issue/randomized-trial-warfarin-communication-protocol-nursing-homes-sbar-based-approach
    November 21, 2012 - Study Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach. Citation Text: Field T, Tjia J, Mazor KM, et al. Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach. Am J Med. 2011;124(2):179.e1-7. doi:1…

  7. Assessing the impact of an electronic chemotherapy order verification checklist on pharmacist reported errors in oncology infusion centers of a health-system. | PSNet

    psnet.ahrq.gov/issue/assessing-impact-electronic-chemotherapy-order-verification-checklist-pharmacist-reported
    January 22, 2016 - Study Assessing the impact of an electronic chemotherapy order verification checklist on pharmacist reported errors in oncology infusion centers of a health-system. Citation Text: Wat SK (S), Wesolowski B, Cierniak K, et al. Assessing the impact of an electronic chemotherapy order verifi…

  8. The disclosure dilemma—large-scale adverse events. | PSNet

    psnet.ahrq.gov/issue/disclosure-dilemma-large-scale-adverse-events
    January 22, 2017 - Commentary The disclosure dilemma—large-scale adverse events. Citation Text: Dudzinski DM, Hébert PC, Foglia MB, et al. The disclosure dilemma--large-scale adverse events. New Engl J Med. 2010;363(10):978-986. doi:10.1056/NEJMhle1003134. Copy Citation Format: DOI Google S…

  9. Errors and error-producing conditions during a simulated, prehospital, pediatric cardiopulmonary arrest. | PSNet

    psnet.ahrq.gov/issue/errors-and-error-producing-conditions-during-simulated-prehospital-pediatric-cardiopulmonary
    August 25, 2021 - Study Errors and error-producing conditions during a simulated, prehospital, pediatric cardiopulmonary arrest. Citation Text: Lammers RL, Willoughby-Byrwa M, Fales WD. Errors and error-producing conditions during a simulated, prehospital, pediatric cardiopulmonary arrest. Simul Healthc. …

  10. Improving feedback on junior doctors' prescribing errors: mixed-methods evaluation of a quality improvement project. | PSNet

    psnet.ahrq.gov/issue/improving-feedback-junior-doctors-prescribing-errors-mixed-methods-evaluation-quality
    July 11, 2018 - Review Improving feedback on junior doctors' prescribing errors: mixed-methods evaluation of a quality improvement project. Citation Text: Reynolds M, Jheeta S, Benn J, et al. Improving feedback on junior doctors' prescribing errors: mixed-methods evaluation of a quality improvement proj…

  11. Reflecting on diagnostic errors: taking a second look is not enough. | PSNet

    psnet.ahrq.gov/issue/reflecting-diagnostic-errors-taking-second-look-not-enough
    September 26, 2016 - Study Reflecting on diagnostic errors: taking a second look is not enough. Citation Text: Monteiro SD, Sherbino J, Patel A, et al. Reflecting on Diagnostic Errors: Taking a Second Look is Not Enough. J Gen Intern Med. 2015;30(9):1270-4. doi:10.1007/s11606-015-3369-4. Copy Citation …

  12. Translating staff experience into organisational improvement: the HEADS-UP stepped wedge, cluster controlled, non-randomised trial. | PSNet

    psnet.ahrq.gov/issue/translating-staff-experience-organisational-improvement-heads-stepped-wedge-cluster
    April 24, 2018 - Study Translating staff experience into organisational improvement: the HEADS-UP stepped wedge, cluster controlled, non-randomised trial. Citation Text: Pannick S, Athanasiou T, Long SJ, et al. Translating staff experience into organisational improvement: the HEADS-UP stepped wedge, clus…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46037/psn-pdf
    April 16, 2018 - 'If no-one stops me, I'll make the mistake again': changing prescribing behaviours through feedback; a Perceptual Control Theory perspective. April 16, 2018 Ferguson J, Keyworth C, Tully MP. 'If no-one stops me, I'll make the mistake again': Changing prescribing behaviours through feedback; A Perceptual Control Th…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39241/psn-pdf
    March 05, 2010 - Dealing honestly with an honest mistake. March 5, 2010 Liang NL, Herring ME, Bush RL. Dealing honestly with an honest mistake. J Vasc Surg. 2010;51(2):494-5. doi:10.1016/j.jvs.2009.11.001. https://psnet.ahrq.gov/issue/dealing-honestly-honest-mistake This case report describes a near miss involving a potential hepa…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39771/psn-pdf
    August 18, 2010 - Bearing witness to the ethics of practice: storying physicians' medical mistake narratives. August 18, 2010 Carmack HJ. Bearing witness to the ethics of practice: storying physicians' medical mistake narratives. Health Commun. 2010;25(5):449-58. doi:10.1080/10410236.2010.484876. https://psnet.ahrq.gov/issue/bearin…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37148/psn-pdf
    March 11, 2009 - CMS: your mistake, your problem. March 11, 2009 Lubell J. CMS: your mistake, your problem. Eight hospital-acquired conditions won't be paid for. Modern healthcare. 2007;37(33):10-1. https://psnet.ahrq.gov/issue/cms-your-mistake-your-problem This article discusses the challenges hospitals face in responding to rece…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37044/psn-pdf
    September 05, 2007 - Make no mistake about it: chain pharmacies are finding innovative ways to combat medication errors. September 5, 2007 Levy S. Drug Topics. July 9, 2007 https://psnet.ahrq.gov/issue/make-no-mistake-about-it-chain-pharmacies-are-finding-innovative-ways- combat-medication This article reports on ways in which chain …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42753/psn-pdf
    November 20, 2013 - Dealing with a medical mistake: should physicians apologize to patients? November 20, 2013 Tabler NG Jr. https://psnet.ahrq.gov/issue/dealing-medical-mistake-should-physicians-apologize-patients This article discusses how apologies address patients' needs when a medical mistake has occurred and how such disclosur…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39344/psn-pdf
    March 03, 2010 - Mistake-proofing healthcare: why stopping processes may be a good start. March 3, 2010 Grout JR, Toussaint JS. Mistake-proofing healthcare: Why stopping processes may be a good start. Bus Horiz. 2009;53(2):149-156. doi:10.1016/j.bushor.2009.10.007. https://psnet.ahrq.gov/issue/mistake-proofing-healthcare-why-stopp…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39634/psn-pdf
    December 04, 2016 - We meant no harm, yet we made a mistake; why not apologize for it? A student's view. December 4, 2016 Sanford DE, Fleming DA. We meant no harm, yet we made a mistake; why not apologize for it? A student's view. HEC Forum. 2010;22(2):159-69. doi:10.1007/s10730-010-9131-8. https://psnet.ahrq.gov/issue/we-meant-no-ha…
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