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Showing results for "mistakes".

  1. Hospital image repair strategies, organizational apology, and medical errors: an analysis of the CoxHealth brain over-radiation case. | PSNet

    psnet.ahrq.gov/issue/hospital-image-repair-strategies-organizational-apology-and-medical-errors-analysis-coxhealth
    July 17, 2024 - Commentary Hospital image repair strategies, organizational apology, and medical errors: an analysis of the CoxHealth brain over-radiation case. Citation Text: Carmack HJ. Hospital Image Repair Strategies, Organizational Apology, and Medical Errors: An Analysis of the CoxHealth Brain Ove…

  2. Implementation of a "second victim" program in a pediatric hospital. | PSNet

    psnet.ahrq.gov/issue/implementation-second-victim-program-pediatric-hospital
    December 18, 2013 - Study Implementation of a "second victim" program in a pediatric hospital. Citation Text: Krzan KD, Merandi J, Morvay S, et al. Implementation of a "second victim" program in a pediatric hospital. Am J Health Syst Pharm. 2015;72(7):563-7. doi:10.2146/ajhp140650. Copy Citation Forma…

  3. Considering human factors and developing systems-thinking behaviours to ensure patient safety. | PSNet

    psnet.ahrq.gov/issue/considering-human-factors-and-developing-systems-thinking-behaviours-ensure-patient-safety
    March 01, 2023 - Newspaper/Magazine Article Considering human factors and developing systems-thinking behaviours to ensure patient safety. Citation Text: Considering human factors and developing systems-thinking behaviours to ensure patient safety. Vosper H; Lim R; Knight C; et al; CIEHF Pharmaceutical H…

  4. Lost, mislabeled, and mishandled surgical and clinical pathology specimens: a systematic review of published literature. | PSNet

    psnet.ahrq.gov/issue/lost-mislabeled-and-mishandled-surgical-and-clinical-pathology-specimens-systematic-review
    September 23, 2020 - Review Lost, mislabeled, and mishandled surgical and clinical pathology specimens: a systematic review of published literature. Citation Text: Carmack HJ, Lazenby BS, Wilson KJ, et al. Lost, mislabeled, and mishandled surgical and clinical pathology specimens: a systematic review of publ…

  5. The stories clinicians tell: achieving high reliability and improving patient safety. | PSNet

    psnet.ahrq.gov/issue/stories-clinicians-tell-achieving-high-reliability-and-improving-patient-safety
    April 24, 2018 - Commentary The stories clinicians tell: achieving high reliability and improving patient safety. Citation Text: Cohen DL, Stewart KO. The Stories Clinicians Tell: Achieving High Reliability and Improving Patient Safety. Perm J. 2016;20(1):85-90. doi:10.7812/TPP/15-039. Copy Citation …

  6. Oncology medication safety: a 3D status report 2008. | PSNet

    psnet.ahrq.gov/issue/oncology-medication-safety-3d-status-report-2008
    March 26, 2015 - Study Oncology medication safety: a 3D status report 2008. Citation Text: Johnson PE, Chambers C, Vaida AJ. Oncology medication safety: a 3D status report 2008. J Oncol Pharm Pract. 2008;14(4):169-80. doi:10.1177/1078155208097634. Copy Citation Format: DOI Google Scholar …

  7. Time out—charting a path for improving performance measurement. | PSNet

    psnet.ahrq.gov/issue/time-out-charting-path-improving-performance-measurement
    March 06, 2005 - Commentary Classic Time out—charting a path for improving performance measurement. Citation Text: MacLean CH, Kerr EA, Qaseem A. Time Out - Charting a Path for Improving Performance Measurement. N Engl J Med. 2018;378(19):1757-1761. doi:10.1056/NEJMp1802595. C…

  8. Disrupting diagnostic reasoning: do interruptions, instructions, and experience affect the diagnostic accuracy and response time of residents and emergency physicians? | PSNet

    psnet.ahrq.gov/issue/disrupting-diagnostic-reasoning-do-interruptions-instructions-and-experience-affect
    February 06, 2014 - Study Disrupting diagnostic reasoning: do interruptions, instructions, and experience affect the diagnostic accuracy and response time of residents and emergency physicians? Citation Text: Monteiro SD, Sherbino JD, Ilgen JS, et al. Disrupting diagnostic reasoning: do interruptions, instr…

  9. Crowdsourcing a diagnosis? Exploring the accuracy of the size and type of group diagnosis: an experimental study. | PSNet

    psnet.ahrq.gov/issue/crowdsourcing-diagnosis-exploring-accuracy-size-and-type-group-diagnosis-experimental-study
    October 27, 2021 - Study Crowdsourcing a diagnosis? Exploring the accuracy of the size and type of group diagnosis: an experimental study. Citation Text: Sherbino J, Sibbald M, Norman GR, et al. Crowdsourcing a diagnosis? Exploring the accuracy of the size and type of group diagnosis: an experimental study…

  10. Patient and family empowerment as agents of ambulatory care safety and quality. | PSNet

    psnet.ahrq.gov/issue/patient-and-family-empowerment-agents-ambulatory-care-safety-and-quality
    December 15, 2021 - Commentary Patient and family empowerment as agents of ambulatory care safety and quality. Citation Text: Roter DL, Wolff JL, Wu AW, et al. Patient and family empowerment as agents of ambulatory care safety and quality. BMJ Qual Saf. 2017;26(6):508-512. doi:10.1136/bmjqs-2016-005489. C…

  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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