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Showing results for "mistakes".

3501. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest | PSNet
      psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
      February 01, 2023 - Early in the career of the freshly graduated physician, there are many things to learn and many mistakes

3502. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49527/psn-pdf
      December 01, 2006 - Mistakes in a stat laboratory: types and frequency. Clin Chem. 1997;43:1348–1351.

3503. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49388/psn-pdf
      February 01, 2003 - A preliminary classification of mistakes. In: Rasumussen J, Duncan K, Lelpat J, eds.

3504. Safemed Facguide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemed_facguide.docx
      May 01, 2017 - Although mistakes are not necessarily more common with these drugs, the consequences of errors are more

3505. Improving Communication and Teamwork in the Surgical Environment Module | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-slides.html
      October 01, 2020 - outside of the operating room/procedure room helps identify items you may want to change without making mistakes

3506. Recurrent Hypoglycemia: A Care Transition Failure? | PSNet
      psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
      December 23, 2020 - features in the emergence of diagnostic errors and the mechanisms through which reflection counteracts mistakes

3507. ABCDEF Bundle Data Literacy Training, Performance Measurement Tracking, and Performance Feedback | PSNet
      psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
      September 23, 2024 - requires additional treatment decisions. 2 The complex care provided in the ICU increases the risk of mistakes

3508. Improving the Safety and Quality of Health Care: The Impact of the National Academy of Medicine on Research and Collaboration (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/dzau-summit2016.pdf
      September 28, 2016 - majority of errors are caused by faulty systems, processes, and conditions that lead people to make mistakes

3509. July Teleconference Transcript (pdf file)
      digital.ahrq.gov/sites/default/files/docs/July%20Teleconference%20Transcript.pdf
      June 16, 2021 - AHRQ 7/13/10 Page 1 Using Health IT to Prevent Adverse Effects COLLIN BUCKLEY: Hello and welcome to the AHRQ webcast, Using Health IT to Prevent Adverse Effects. At this point I’d like to introduce today’s moderator, Doctor Amy Helwig. She’s a medical officer and leads the Patient Safety Organizati…

3510. Don't Use That Port: Insert a PICC | PSNet
      psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
      December 22, 2018 - Don't Use That Port: Insert a PICC Citation Text: Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

3511. Transforming Hospitals | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/transform.html
      December 01, 2017 - Transforming Hospitals Designing for Safety and Quality Transforming Hospitals: Designing for Safety and Quality , a video from the Agency for Healthcare Research and Quality (AHRQ), reviews the case for evidence-based hospital design and how it increases patient and staff satisfaction and safety, quality of …

3512. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49403/psn-pdf
      June 01, 2003 - Missed Appendicitis June 1, 2003 Adams JG. Missed Appendicitis. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missed-appendicitis Case Objectives Appreciate the variable presentations of appendicitis List complications of missed appendicitis Understand the advantages and disadvantages of CT in diagnosing…

3513. New Patient Mistakenly Checked in as Another | PSNet
      psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
      October 01, 2013 - New Patient Mistakenly Checked in as Another Citation Text: Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar B…

3514. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49512/psn-pdf
      May 01, 2006 - Right? Left? Neither! May 1, 2006 Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/right-left-neither Case Objectives Appreciate the role of Reason's Swiss Cheese Model in medical errors Understand the process of analyzing a single error Provide suggestions for …

3515. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33626/psn-pdf
      January 01, 2006 - In Conversation with…Jack Barker, PhD January 1, 2006 In Conversation with…Jack Barker, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withjack-barker-phd Editor's Note: Jack Barker, PhD, is Vice President of Research and Development for Mach One Leadership and a commercial pilot for …

3516. Mistaken Identity | PSNet
      psnet.ahrq.gov/web-mm/mistaken-identity
      December 18, 2014 - Mistaken Identity Citation Text: Hall LW. Mistaken Identity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

3517. Transcript: How To Address Attitudes and Beliefs Around Infection Prevention Strategies and Techniques (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/attitudes-beliefs-transcript.pdf
      April 01, 2022 - Transcript: How To Address Attitudes and Beliefs Around Infection Prevention Strategies and Techniques AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI Transcript How To Address Attitudes and Beliefs Around Infection Prevention Strategies and Techniques Host: Kate Schmidgall …

3518. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49535/psn-pdf
      May 01, 2007 - Production Pressures May 1, 2007 Carayon P. Production Pressures. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/production-pressures The Case A 65-year-old man with bipolar disorder was scheduled for maintenance electroconvulsive therapy (ECT), a procedure he had received dozens of times before. These pro…

3519. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836978/psn-pdf
      May 16, 2022 - Check Twice, Transport Once May 16, 2022 DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/check-twice-transport-once The Case Case #1: A 26-year-old woman (Patient A) presented to the Emergency Department (ED) with abdominal pain and was diagnosed with “s…

3520. Final Progress Report: Producing Evidence: Coordination within a Multiteam System Makes Healthcare Safer (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/jones2-report.pdf
      January 01, 2024 - Learning—Continuous Improvement (α = .86) 85 79 .10 We are actively doing things to improve patient safety. 96 91 .03 Mistakes … Error (α = .84) 69 68 .71 Nonpunitive Response to Error (α = .87) 64 56 .05 Staff feel like their mistakes