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Showing results for "mistakes".

  1. 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…

  2. 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/…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50859/psn-pdf
    January 31, 2020 - paradigm is going to encourage radiologists to slow down and take more time to ensure they make fewer mistakes

  4. Facapplycusp (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/facapplycusp.docx
    June 02, 2025 - System design Humans are fallible and occasionally make mistakes, either through inadvertent errors or

  5. In Conversation With… J. Bryan Sexton, PhD, MA | PSNet

    psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
    February 26, 2025 - When 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.

  6. In Conversation With… David Blumenthal, MD, MPP | PSNet

    psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
    July 01, 2012 - Patient Safety and Health Information Technology: Learning from Our Mistakes July 1, 2012 … Perspective One of the core challenges in patient safety is learning about our mistakes and addressing … diagnosis, the diagnosis is wrong.( 1,2 ) The challenge in patient safety is not only to learn from our mistakes … administration record (e-MAR), and electronic prescribing (eRx)—and examine how we have failed to face our mistakes

  7. In Conversation with…Pat Croskerry, MD, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
    June 01, 2010 - I make mistakes just like the next guy, but hopefully I'm making fewer because I see them coming. … that works best is if you can get senior physician leaders to stand up and admit that they've made mistakes

  8. In Conversation with…Troyen A. Brennan, MD, JD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph
    December 21, 2022 - On the other hand, you have the individual who repetitively makes mistakes. … As your systems get better, it will become harder and harder to make mistakes that otherwise might be

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49705/psn-pdf
    January 01, 2020 - be the most common cognitive error.(9) A separate survey study of diagnostic errors revealed that mistakes … diagnoses).(10) Delays in appropriate referral or consultation were the second most common phase where mistakes

  10. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/forming-cuspteam-facguide.docx
    January 01, 2017 - CUSP is a powerful process that teams employ to recover from mistakes, but also to learn from them and … prevent similar mistakes from happening again.

  11. Forming a Comprehensive Unit-based Safety Program Team: Facilitator Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/mvp/modules/cusp/forming-cusp-team-fac-guide.html
    February 01, 2017 - CUSP is a powerful process that teams employ to recover from mistakes, but also to learn from them and … prevent similar mistakes from happening again.

  12. Learn-From-Defects-Facilitator-Guide (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - These conditions are the mistakes that occur without human error. … Sensemaking is a way for a L&D unit to learn from and prevent mistakes.

  13. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    July 01, 2023 - These conditions are the mistakes that occur without human error. … Sensemaking is a way for a L&D unit to learn from and prevent mistakes.

  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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