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Total Results: 4,019 records

Showing results for "mistakes".

  1. Comprehensive Information Technology Solution for Quality and Patient Safety - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/uc1hs015236-jose-final-report-2008.pdf
    January 01, 2008 - Medication errors are the result of human mistakes or system flaws and are preventable.

  2. In Conversation With…Christine A. Sinsky, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
    February 26, 2025 - Physicians who are burned out make more mistakes.

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33879/psn-pdf
    May 01, 2019 - field and tend to focus on what happens when they finally reach our door, what are some of the common mistakes

  4. Mod01-Grand-Rounds-Slides (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
    April 01, 2016 - greatest impediment to error prevention in the medical industry is that we punish people for making mistakes

  5. Grand Rounds Presentation | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
    August 01, 2022 - greatest impediment to error prevention in the medical industry is that we punish people for making mistakes

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866622/psn-pdf
    August 28, 2024 - at processes through the eyes of the stakeholders to understand complexities and risk concerns for mistakes

  7. Missed CANDOR Implementation Opportunities. | PSNet

    psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
    November 11, 2020 - March 29, 2023 A health system that won't learn from its mistakes.

  8. 023-Ss-Cusp-Learning-From-Defects-Fg (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
    April 01, 2025 - Education can make people aware of the problem, but it alone will not eliminate mistakes. · Vague warnings

  9. AHRQ Nursing Home Survey on Patient Safety Culture: User’s Guide (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/nursing-home/nursinghome-users-guide.pdf
    April 01, 2022 - promotes resident safety and shows that resident safety is a top priority. 3 Nonpunitive Response to Mistakes … Staff are not blamed when a resident is harmed, are treated fairly when they make mistakes, and feel … safe reporting their mistakes. 4 Organizational Learning There is a learning culture that facilitates

  10. Final Progress Report: Implementing a Program of Patient Safety in Small, Rural Hospitals (pdf file)

    www.ahrq.gov/sites/default/files/2024-02/jones-report.pdf
    January 01, 2024 - more authority (41% and 46%)—and from the nonpunitive response to error dimension—staff worry that mistakes … • The odds of a respondent disagreeing in 2007 that they worry that mistakes they make are kept in

  11. Final Progress Report: Cook County & Rush Developmental Center for Research in Patient Safety: Diagnosis Error Evaluation and Research (DEER) Project (pdf file)

    www.ahrq.gov/sites/default/files/2025-04/schiff-mcnutt-report.pdf
    January 01, 2025 - can identify errors with definite deviations from standard of expected care, though, in which clear mistakes … Diagnosing Diagnostic Mistakes. AHRQ Web M&M: Morbidity and Mortality Rounds on the Web; May 2005.

  12. Final Progress Report: Risk-Informed Interventions in Community Pharmacy: Implementation and Evaluation (pdf file)

    www.ahrq.gov/sites/default/files/2024-02/cohen2-report.pdf
    January 01, 2024 - Final Progress Report: Risk-Informed Interventions in Community Pharmacy: Implementation and Evaluation Final Report: Risk-Informed Interventions in Community Pharmacy: Implementation and Evaluation Principal Investigator: Michael R. Cohen, RPh, MS, ScD (hon), DPS (hon) Team Members: Judy L. Smetzer, RN, BSN,…

  13. Liver Biopsy: Proceed With Caution | PSNet

    psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
    March 07, 2012 - Liver Biopsy: Proceed With Caution Citation Text: Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

  14. Production Pressures | PSNet

    psnet.ahrq.gov/web-mm/production-pressures
    November 16, 2022 - Production Pressures Citation Text: Carayon P. Production Pressures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

  15. Too Tight Control | PSNet

    psnet.ahrq.gov/web-mm/too-tight-control
    March 20, 2013 - SPOTLIGHT CASE Too Tight Control Citation Text: Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…

  16. Delayed Recognition of a Positive Blood Culture | PSNet

    psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
    January 29, 2020 - Delayed Recognition of a Positive Blood Culture Citation Text: Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibT…

  17. The ECG Is Not Normal | PSNet

    psnet.ahrq.gov/web-mm/ecg-not-normal
    November 10, 2015 - SPOTLIGHT CASE The ECG Is Not Normal Citation Text: Zuger A. The ECG Is Not Normal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49859/psn-pdf
    April 01, 2019 - E-cigarette Explosion in a Patient Room April 1, 2019 Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room The Case A 49-year-old woman was admitted for an exacerbation of chronic obstructive pulmonary disease (COPD) without…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49799/psn-pdf
    July 01, 2017 - Delayed Recognition of a Positive Blood Culture July 1, 2017 Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture The Case A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49828/psn-pdf
    May 01, 2018 - Out of Sight, Out of Mind: Out-of-Office Test Result Management May 1, 2018 Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management Case Objectives Recognize the general responsibilities of…
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