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Showing results for "mistakes".

  1. Coronavirus: can this California prison save itself from Covid-19? | PSNet

    psnet.ahrq.gov/issue/coronavirus-can-california-prison-save-itself-covid-19
    July 01, 2020 - Newspaper/Magazine Article Coronavirus: can this California prison save itself from Covid-19? Citation Text: Honderich H, Popat S. Coronavirus: Can this California prison save itself from Covid-19? BBC News, Washington. 2020;Jul 27. Copy Citation Format: Google Scholar BibT…

  2. The differences between human error, at-risk behavior, and reckless behavior are key to a just culture. | PSNet

    psnet.ahrq.gov/issue/differences-between-human-error-risk-behavior-and-reckless-behavior-are-key-just-culture
    September 23, 2020 - Newspaper/Magazine Article The differences between human error, at-risk behavior, and reckless behavior are key to a just culture. Citation Text: The differences between human error, at-risk behavior, and reckless behavior are key to a just culture. ISMP Medication Safety Alert! Acute Ca…

  3. Does physician's training induce overconfidence that hampers disclosing errors? | PSNet

    psnet.ahrq.gov/issue/does-physicians-training-induce-overconfidence-hampers-disclosing-errors
    October 21, 2009 - Study Does physician's training induce overconfidence that hampers disclosing errors? Citation Text: Brezis M, Orkin-Bedolach Y, Fink D, et al. Does Physician's Training Induce Overconfidence That Hampers Disclosing Errors? J Patient Saf. 2019;15(4):296-298. doi:10.1097/PTS.0000000000000…

  4. To forgive, divine. | PSNet

    psnet.ahrq.gov/issue/forgive-divine
    November 11, 2020 - Commentary To forgive, divine. Citation Text: Johnson V. To forgive, divine. N Engl J Med. 2024;391(1):6-7. doi:10.1056/nejmp2402006. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation …

  5. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. | PSNet

    psnet.ahrq.gov/issue/diagnostic-blood-loss-phlebotomy-and-hospital-acquired-anemia-during-acute-myocardial
    March 14, 2022 - Study Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Citation Text: Salisbury AC, Reid KJ, Alexander KP, et al. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med…

  6. Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber order entry. | PSNet

    psnet.ahrq.gov/issue/safe-chemotherapy-administration-using-failure-mode-and-effects-analysis-computerized
    October 19, 2022 - Commentary Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber order entry. Citation Text: Kozakiewicz JM, Benis LJ, Fisher SM, et al. Safe chemotherapy administration: Using failure mode and effects analysis in computerized prescriber o…

  7. Design for patient safety: a systems-based risk identification framework. | PSNet

    psnet.ahrq.gov/issue/design-patient-safety-systems-based-risk-identification-framework
    February 03, 2021 - Study Emerging Classic Design for patient safety: a systems-based risk identification framework. Citation Text: Simsekler MCE, Ward JR, Clarkson J. Design for patient safety: a systems-based risk identification framework. Ergonomics. 2018;61(8):1046-1064. doi:10…

  8. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills. | PSNet

    psnet.ahrq.gov/issue/key-performance-outcomes-patient-safety-curricula-root-cause-analysis-failure-mode-and
    July 23, 2010 - Commentary Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills. Citation Text: Fassett WE. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects …

  9. Sensemaking of patient safety risks and hazards. | PSNet

    psnet.ahrq.gov/issue/sensemaking-patient-safety-risks-and-hazards
    March 03, 2011 - Commentary Sensemaking of patient safety risks and hazards. Citation Text: Battles J, Dixon NM, Borotkanics RJ, et al. Sensemaking of patient safety risks and hazards. Health Serv Res. 2006;41(4 Pt 2):1555-1575. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X…

  10. A team disclosure of error educational activity: objective outcomes. | PSNet

    psnet.ahrq.gov/issue/team-disclosure-error-educational-activity-objective-outcomes
    January 31, 2018 - Study A team disclosure of error educational activity: objective outcomes. Citation Text: Krumwiede KH, Wagner JM, Kirk LM, et al. A Team Disclosure of Error Educational Activity: Objective Outcomes. J Am Geriatr Soc. 2019;67(6):1273-1277. doi:10.1111/jgs.15883. Copy Citation Forma…

  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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