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Showing results for "mistakes".

561. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39296/psn-pdf
     January 22, 2017 - Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. January 22, 2017 Aboumatar HJ, Winner L, Davis RO, et al. Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. Jt Comm J Qual Patient Saf. 2010;36(2):79-86. https://psnet.ahrq.gov/issue/applying-lea…

562. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841774/psn-pdf
     December 21, 2022 - The prosecution of RaDonda Vaught: an ethical and legal mistake. December 21, 2022 Vogelstein E. The prosecution of RaDonda Vaught: An ethical and legal mistake. Nurs Forum. 2022;57(6):1571-1574. doi:10.1111/nuf.12838. https://psnet.ahrq.gov/issue/prosecution-radonda-vaught-ethical-and-legal-mistake The criminal …

563. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45355/psn-pdf
     September 28, 2016 - psnet.ahrq.gov/issue/getting-it-right-patient-safety-specimen-collection-process-improvement- operating-room Mistakes

564. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60717/psn-pdf
     July 22, 2020 - The U.S. is repeating its deadliest pandemic mistake. July 22, 2020 KHAZAN OLGA. The U.S. is repeating its deadliest pandemic mistake. The Atlantic. 2020;July 6. https://psnet.ahrq.gov/issue/us-repeating-its-deadliest-pandemic-mistake Residential care facilities have been particularly challenged by COVID-19. This a…

565. Tolerating uncertainty—the next medical revolution? | PSNet
     psnet.ahrq.gov/issue/tolerating-uncertainty-next-medical-revolution
     April 24, 2018 - September 1, 2018 Mistakes were made (by me). … October 18, 2017 Inpatient Notes: mistakes in the hospital—communicating, apologizing

566. Checklists improve experts' diagnostic decisions. | PSNet
     psnet.ahrq.gov/issue/checklists-improve-experts-diagnostic-decisions
     February 06, 2014 - February 6, 2014 Finding and fixing mistakes: do checklists work for clinicians with … December 27, 2014 Finding and fixing mistakes: do checklists work for clinicians with

567. 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…

568. 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…

569. 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…

570. 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…

571. 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…

572. 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 …

573. 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…

574. 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…

575. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39129/psn-pdf
     November 25, 2009 - How to avoid falling victim to a hospital mistake. November 25, 2009 Cohen E. https://psnet.ahrq.gov/issue/how-avoid-falling-victim-hospital-mistake This news story describes an incident of patient misidentification and offers tips to help patients confirm their care during a hospitalization. https://psnet.ahrq.g…

576. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38882/psn-pdf
     November 14, 2011 - Dead by Mistake. November 14, 2011 Crowley CF, Nalder E. New York, NY: Hearst Digital News; August 2009. https://psnet.ahrq.gov/issue/dead-mistake This Web site provides access to numerous materials relating stories of medical harm and reporting data as well as contextual information from a news media investigatio…

577. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42766/psn-pdf
     November 27, 2013 - The biggest mistake doctors make. November 27, 2013 Landro L. Wall Street Journal. November 17, 2013. https://psnet.ahrq.gov/issue/biggest-mistake-doctors-make This newspaper article describes efforts to prevent diagnostic errors, including improving follow-up of abnormal test results and implementing decision sup…

578. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36892/psn-pdf
     December 01, 2017 - Mistake-Proofing the Design of Health Care Processes. December 1, 2017 Grout JR. Rockville, MD: Agency for Healthcare Research and Quality; May 2007. AHRQ Publication No. 07-0020. https://psnet.ahrq.gov/issue/mistake-proofing-design-health-care-processes In this report, the author draws from multidisciplinary sour…

579. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34597/psn-pdf
     March 28, 2005 - Mistaking error. March 28, 2005 Cook RI, Woods DD. Chapter in: Youngberg BJ, Hatlie, MJ, ed. Patient Safety Handbook, Sudbury, MA: Jones and Bartlett; 2004. https://psnet.ahrq.gov/issue/mistaking-error This chapter discusses the "New Look" as a paradigm shift in understanding the complexity of error and how to se…

580. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43545/psn-pdf
     September 17, 2014 - Feds reverse course, will release hospital mistake data. September 17, 2014 https://psnet.ahrq.gov/issue/feds-reverse-course-will-release-hospital-mistake-data This newspaper article reports on the decision to reinstate distribution of publicly-reported information on hospital-acquired conditions that, in an attemp…