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Showing results for "mistakes".

  1. The Wet Read | PSNet

    psnet.ahrq.gov/web-mm/wet-read
    October 01, 2017 - Junior residents make more mistakes than more senior residents, fellows, or faculty. … Around-the-clock attending radiology coverage is essential to avoid mistakes in the care of trauma patients

  2. SOPS Frequently Asked Questions | Agency for Healthcare Research and Quality

    www.ahrq.gov/sops/about/faq/index.html
    June 01, 2022 - Response to Mistakes (3 items). Handoffs and Information Exchange (3 items). Speaking Up (2 items). … The composite measures in the community pharmacy survey are: Communication About Mistakes. … Response to Mistakes. Staff Training and Skills. Staffing, Work Pressure, and Pace. Teamwork. … , the community pharmacy survey also includes several single item measures that assess: Documenting mistakes … Response to Mistakes. Management Support for Patient Safety.

  3. The University of Wisconsin-Madison Multidisciplinary Graduate Certificate in Patient Safety (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Karsh.pdf
    April 08, 2004 - fatigue), physician-patient communication, communication within the health care team, learning from mistakes … curriculum: ethics (transparency and truthfulness), a proactive approach to error in health care, framing mistakes … (i.e., the system vs. individual), reporting error and follow-up, learning from mistakes, staffing … This topic includes models of medical decisionmaking, how mistakes are made in decisionmaking, and

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33752/psn-pdf
    August 01, 2013 - you're burned out you're not engaged, so you do things that are more expensive, you make the same mistakes … again and again, and tragically, you don't even notice that you're making the mistakes.

  5. Secret data on hospital inspections may soon become public. | PSNet

    psnet.ahrq.gov/issue/secret-data-hospital-inspections-may-soon-become-public
    January 30, 2019 - October 3, 2017 Hidden mistakes in hospitals. … October 3, 2017 More families hear apologies following medical mistakes.

  6. 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

  7. In Conversation With… Rosemary Gibson, MSc | PSNet

    psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
    September 01, 2014 - increase, stress on the delivery system to do more in the same amount of time heightens the risk of mistakes … When a system with defects is forced to operate at a faster pace, performance degrades and mistakes increase … excess diagnoses or additional treatments, which in turn creates "more to do" and ultimately can lead to mistakes

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865346/psn-pdf
    March 27, 2024 - RaDonda Vaught says some system practices contributed to fatal mistake. March 27, 2024 Clark C. MedPage Today. March 14, 2024. https://psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake Stories from clinicians involved in errors provide unique insights into both the human an…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72658/psn-pdf
    January 20, 2021 - “I made a mistake!”: a narrative analysis of experienced physicians' stories of preventable error. January 20, 2021 Kandasamy S, Vanstone M, Colvin E, et al. “I made a mistake!”: a narrative analysis of experienced physicians' stories of preventable error. J Eval Clin Pract. 2021;27(2):236-245. doi:10.1111/jep.1353…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47957/psn-pdf
    April 24, 2019 - A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I'm afraid that's exactly what it was. April 24, 2019 Maskell G. A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I'm afraid that's exactly what it was. BMJ. 2019;365:l1617. doi:…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38894/psn-pdf
    August 26, 2009 - Negotiating medical virtues: toward the development of a physician mistake disclosure model. August 26, 2009 Hannawa AF. Negotiating medical virtues: toward the development of a physician mistake disclosure model. Health Comm. 2009;24(5):391-399. doi:10.1080/10410230903023279. https://psnet.ahrq.gov/issue/negotiat…

  12. 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…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39964/psn-pdf
    January 04, 2011 - Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine? January 4, 2011 Reddy K, Brown B, Nanda A. Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine? Clin Neurol Neurosurg. 2011;113(1):68-71. doi:10.1016/…

  14. 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…

  15. 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…

  16. 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…

  17. 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…

  18. 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 …

  19. 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…

  20. 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…
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