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Total Results: 4,019 records

Showing results for "mistakes".

3041. The Wrong Channel | PSNet
      psnet.ahrq.gov/web-mm/wrong-channel
      February 01, 2003 - Another project that observed nurses administering IV medications found 265 so-called mistakes, slips

3042. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33788/psn-pdf
      June 01, 2015 - The patient safety world is all about measuring when mistakes or bad things happen.

3043. Rediscovering the Power of the Surgical M&M Conference: The M M Matrix | PSNet
      psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
      September 01, 2007 - Internal bleeding: the truth behind America's terrifying epidemic of medical mistakes. … frustrated after we realized in the last several years that we had no idea if we were making fewer mistakes … September 20, 2011 Learning from mistakes: factors that influence how students and residents

3044. Patient Safety: A Perspective from Office Practice | PSNet
      psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
      May 01, 2009 - A phenomenologic analysis of medical mistakes argues that a better way to frame mistakes is to think … The Unity of Mistakes: A Phenomenological Analysis of Medical Work.

3045. Disposition of Comments Report for Allergen-Specific Immunotherapy for the Treatment of Allergic Rhinoconjunctivitis and/or Asthma (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/asthma-immunotherapy-2010_disposition-comments.pdf
      January 01, 2010 - revised all the sections in the report to make sure the numbers were consistent and corrected the mistakes … Thank you for your comment, We noted the mistakes and corrected them 11 Peer Reviewer #2 Results … We revised all numbers in the text and the ES and corrected the mistakes Source: http://effectivehealthcare.ahrq.gov … We revised all numbers in the text and the ES and corrected the mistakes 31 Peer Reviewer #4

3046. Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-psychological-safety.pdf
      September 01, 2023 - encourages individuals “to express their ideas and concerns, to speak up with questions, and to admit mistakes … program that uses interpersonal relationships to assess and enhance performance; this program recognizes mistakes

3047. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49703/psn-pdf
      March 01, 2014 - After-Visit Confusion March 1, 2014 Ventres W. After-Visit Confusion. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/after-visit-confusion The Case An otherwise healthy 18-year-old woman presented to an urgent care clinic with new bumps and white spots near her tongue. The patient's mother accompanied her …

3048. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50842/psn-pdf
      January 29, 2020 - Patient Identification Errors: A Systems Challenge January 29, 2020 Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge The Cases The following four events involving five patients all involved…

3049. Mutual Support: Severe Hypertension (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support-speaker-notes.pdf
      July 01, 2023 - Often we are already aware of our limitations, shortcomings, and mistakes. … People can feel targeted and embarrassed when their mistakes are pointed out in public, and they may … Recognize that we are all trying to do the best we can and making mistakes is hard on us.

3050. Mutual Support: Severe Hypertension - PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support.pptx
      July 01, 2023 - Often we are already aware of our limitations, shortcomings, and mistakes. … People can feel targeted and embarrassed when their mistakes are pointed out in public, and they may … Recognize that we are all trying to do the best we can and making mistakes is hard on us.

3051. Interpreting the Patient Safety Literature | PSNet
      psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
      June 01, 2005 - Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. … Yet we also learned that despite all this, we often fail to learn from these defects; mistakes recur.

3052. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854897/psn-pdf
      October 31, 2023 - intercepting errors.6 Some healthcare professionals thus question their impact on safety, arguing that mistakes

3053. Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/modules/apply/ac-cusp.html
      December 01, 2012 - System design Humans are fallible and occasionally make mistakes, either through inadvertent errors

3054. Learn About the Comprehensive Unit-Based Safety Program for Perinatal Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-about-cusp-facilitator-guide.pdf
      May 01, 2017 - Slide 18 SAY: System design Humans are fallible and occasionally make mistakes, either through inadvertent

3055. Catheter Types and Being Part of the Insertion Team
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/indwelling-urinary-catheteruse/catheter-insertion/licensed-staff/licensed-catheter.pptx
      March 01, 2017 - an indwelling urinary catheter, using aseptic technique, let’s go over some things to avoid common mistakes

3056. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49645/psn-pdf
      February 01, 2012 - physicians to send or call in amended prescription information to the pharmacy to avoid repeating mistakes

3057. The Inside of a Time Out | PSNet
      psnet.ahrq.gov/web-mm/inside-time-out
      March 01, 2004 - analyses of wrong site surgeries reveal that most emanate from the OR itself, but it is clear that mistakes

3058. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
      January 29, 2008 - Errors Addressed by System Change Medical mistakes caused by latent errors, such as similar sounding … consequences from error-related communications serve to reduce such reporting and limit learning from mistakes … unavoidable and necessary feature of their work.56, 57, 58 It has even been argued that errors and mistakes … needs to be modified so caregivers and their patients feel safe reporting and learning from medical mistakes

3059. In Conversation With… Richard C. Boothman, JD | PSNet
      psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
      March 01, 2012 - Boothman joined the University in 2001, and soon developed a pioneering approach to medical mistakes … the time, was by all means we should learn from our patients' experiences, we should learn from our mistakes

3060. Failure Mode and Effects Analysis | Digital Healthcare Research
      digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/fmea-analysis
      January 01, 2023 - Failure Mode and Effects Analysis Acronym FMEA Also Known As Failure Mode, Effects, and Criticality Analysis (FMECA) Potential Failure Modes and Effects Analysis Examples Wetterneck TB, Skibinski KA, Roberts TL, et al. Using failure mode and effects analysis to plan implementat…