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Total Results: 3,093 records

Showing results for "mistakes".

  1. Insights from the sharp end of intravenous medication errors: implications for infusion pump technology. | PSNet

    psnet.ahrq.gov/issue/insights-sharp-end-intravenous-medication-errors-implications-infusion-pump-technology
    January 23, 2017 - Study Insights from the sharp end of intravenous medication errors: implications for infusion pump technology. Citation Text: Husch M. Insights from the sharp end of intravenous medication errors: implications for infusion pump technology. Quality and Safety in Health Care. 2005;14(2).…

  2. Using prospective risk analysis tools to improve safety in pharmacy settings: a systematic review and critical appraisal. | PSNet

    psnet.ahrq.gov/issue/using-prospective-risk-analysis-tools-improve-safety-pharmacy-settings-systematic-review-and
    January 24, 2018 - Review Using prospective risk analysis tools to improve safety in pharmacy settings: a systematic review and critical appraisal. Citation Text: Stojkovic T, Marinkovic V, Manser T. Using Prospective Risk Analysis Tools to Improve Safety in Pharmacy Settings: A Systematic Review and Criti…

  3. Liability reform should make patients safer: "Avoidable classes of events" are a key improvement. | PSNet

    psnet.ahrq.gov/issue/liability-reform-should-make-patients-safer-avoidable-classes-events-are-key-improvement
    July 26, 2023 - Commentary Liability reform should make patients safer: "Avoidable classes of events" are a key improvement. Citation Text: Bovbjerg RR, Tancredi LR. Liability reform should make patients safer: "avoidable classes of events" are a key improvement. J Law Med Ethics. 2005;33(3):478-500. …

  4. Implementation of a high-reliability organization framework in a large integrated health care system: a pre-post quasi-experimental quality improvement project. | PSNet

    psnet.ahrq.gov/issue/implementation-high-reliability-organization-framework-large-integrated-health-care-system
    July 14, 2018 - Study Implementation of a high-reliability organization framework in a large integrated health care system: a pre-post quasi-experimental quality improvement project. Citation Text: Sawyer AM, Thiyarajan S, Essen KE, et al. Implementation of a high-reliability organization framework in a…

  5. Assessing the perceived level of institutional support for the second victim after a patient safety event. | PSNet

    psnet.ahrq.gov/issue/assessing-perceived-level-institutional-support-second-victim-after-patient-safety-event
    April 07, 2021 - Study Assessing the perceived level of institutional support for the second victim after a patient safety event. Citation Text: Joesten L, Cipparrone N, Okuno-Jones S, et al. Assessing the perceived level of institutional support for the second victim after a patient safety event. J Pati…

  6. The Harvard Medical Practice Study trigger system performance in deceased patients. | PSNet

    psnet.ahrq.gov/issue/harvard-medical-practice-study-trigger-system-performance-deceased-patients
    March 02, 2022 - Study The Harvard Medical Practice Study trigger system performance in deceased patients. Citation Text: Klein DO, Rennenberg RJMW, Koopmans RP, et al. The Harvard medical practice study trigger system performance in deceased patients. BMC Health Serv Res. 2019;19(1):16. doi:10.1186/s129…

  7. 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…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33610/psn-pdf
    April 01, 2005 - influential AHRQ-supported New England Journal of Medicine study on housestaff sleep deprivation and medical mistakes

  9. In Conversation With... Remle P. Crowe, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
    May 16, 2022 - safety: whether or not it's an open communication environment, what is the response when there are mistakes … We're talking about things like staffing, teamwork, and the non-punitive response to mistakes, so all … going to compare ourselves to aviation in that there's a lot of complexity and a lot of potential for mistakes

  10. Operationalizing Patient Safety at Academic Medical Centers | PSNet

    psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
    August 01, 2010 - help ensure a positive safety climate, one in which individuals are not blamed for innocent slips and mistakes … Second, trainees must improve their communication skills as they relate to discussion of medical mistakes … AMCs to be leaders in providing safe care, performing the research needed to understand how to prevent mistakes

  11. In Conversation with…William B. Weeks, MD, MBA | PSNet

    psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
    May 01, 2009 - A phenomenologic analysis of medical mistakes argues that a better way to frame mistakes is to think … The Unity of Mistakes: A Phenomenological Analysis of Medical Work.

  12. In Conversation with...Richard P. Shannon, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
    August 01, 2010 - help ensure a positive safety climate, one in which individuals are not blamed for innocent slips and mistakes … Second, trainees must improve their communication skills as they relate to discussion of medical mistakes … AMCs to be leaders in providing safe care, performing the research needed to understand how to prevent mistakes

  13. 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…

  14. Identifying Safety Events in the Prehospital Setting | PSNet

    psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
    May 16, 2022 - safety: whether or not it's an open communication environment, what is the response when there are mistakes … We're talking about things like staffing, teamwork, and the non-punitive response to mistakes, so all … going to compare ourselves to aviation in that there's a lot of complexity and a lot of potential for mistakes

  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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