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Showing results for "mistakes".

3661. Development and Evaluation of Socio-Technical Metricsto Inform HIT Adaptation - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs024767-yen-final-report-2019.pdf
      January 01, 2019 - Development and Evaluation of Socio-Technical Metricsto Inform HIT Adaptation - Final Report R21 HS024767-02 Development and Evaluation of Socio-Technical Metrics to Inform HIT Adaptation Final P rogress Report Principal Investigator: Po-Yin Yen, PhD, RN Assistant Professor …

3662. Small and Rural and Critical Access Hospitals (Transcript) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals.html
      April 01, 2013 - for the Comprehensive Unit-based Safety Program, and it’s a cultural intervention to learn from our mistakes … It keeps the focus and it prevents us from making mistakes.

3663. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851099/psn-pdf
      June 28, 2023 - Misconnection Leading to Arterial Thrombosis June 28, 2023 Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis The Case A 55-year-old man with chronic obstructive pulmonary disease (COPD) was brought by am…

3664. Right Regimen, Wrong Cancer: Patient Catches Medical Error | PSNet
      psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
      August 01, 2006 - SPOTLIGHT CASE Right Regimen, Wrong Cancer: Patient Catches Medical Error Citation Text: Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…

3665. Facilitator Guide: Auditing Your Briefings and Debriefings (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_audit_briefing_facnotes.docx
      December 01, 2017 - Facilitator Guide: Auditing Your Briefings and Debriefings Slide Title and Commentary Slide Number and Slide Auditing Your Briefing and Debriefing Process SAY: Let’s continue our discussion around briefings and debriefings. The previous module, Optimizing Your Briefings and Debriefings, focused on defining them…

3666. Auditing Your Briefings and Debriefings Process: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/implementation/audit-briefing-fac-notes.html
      December 01, 2017 - Auditing Your Briefings and Debriefings Process: Facilitator Notes AHRQ Safety Program for Surgery Slide 1: Auditing Your Briefing and Debriefing Process Say: Let’s continue our discussion around briefings and debriefings. The previous module, Optimizing Your Briefings and Debriefings, focused on defini…

3667. Disposition of Comments for CER 178 Newer Medications for Lower Urinary Tract Symptoms (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/prostatic-hyperplasia-medications_disposition-comments.pdf
      May 26, 2016 - The limitations section needs more editing as there are several editorial mistakes. Thank you.

3668. Cauti-Sustainability-Transcript (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/cauti-sustainability-transcript.docx
      January 01, 2014 - Your senior executive partnership is important and apply learning from our mistakes and using the tool

3669. Situation Monitoring: Severe Hypertension (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_4-situation-monitoring-speaker-notes.pdf
      July 01, 2023 - 29 • Errors – Were mistakes made? Were there any near misses? … How could mistakes and near misses be prevented?

3670. Evidence Summary: Bladder Cancer in Adults: Screening | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary14/bladder-cancer-in-adults-screening
      October 15, 2010 - Share to Facebook Share to X Share to WhatsApp Share to Email Print Evidence Summary Bladder Cancer in Adults: Screening October 15, 2010 Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as…

3671. Preventing CAUTI in Special Populations: Focus on Procedure-Related Catheter Use (July 8, 2014) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/preventing-cauti-focus-procedure-related-transcript.html
      December 01, 2017 - Preventing CAUTI in Special Populations: Focus on Procedure-Related Catheter Use (July 8, 2014) Webinar Transcript July National Content Call July 8, 2014 11:00AM CT Operator: This is a recording of the Paul Tedrick conference, the July National Content Call, on July 8, 2014 at 11:00AM Central. Excuse …

3672. Paul Tedrick (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-focus-procedure-related-cath-use-transcript.doc
      July 08, 2014 - Paul Tedrick July National Content Call July 8, 2014 11:00AM CT Operator: This is a recording of the Paul Tedrick conference, the July National Content Call, on July 8, 2014 at 11:00AM Central. Excuse me, everyone. We now have our speakers in conference. Please note the participation on this call is by express wri…

3673. Navigating-Hierarchy-Transcript (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/navigating-hierarchy-transcript.doc
      December 10, 2013 - system and not just in the U.S. but it’s a pretty universal thing, is that we don’t talk about our mistakes

3674. Navigating Hierarchy in the Clinical Setting: Working and Communicating with Others (December 10, 2013) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/navigating-hierarchy-transcript.html
      December 01, 2017 - system and not just in the U.S. but it's a pretty universal thing, is that we don't talk about our mistakes

3675. CAUTI Sustainability: Embedding CAUTI Policies, Using Data to Monitor Proress and Hardwiring CUSP Principles | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/cauti-sustainability-transcript.html
      December 01, 2017 - Your senior executive partnership is important and apply learning from our mistakes and using the tool

3676. Health Care Data Science for Quality Improvement and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
      October 01, 2016 - Perspective Patient Safety and Health Information Technology: Learning from Our Mistakes

3677. Advancing Patient Safety: A Decade of Evidence, Design, and Implementation (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/advancing-patient-safety.pdf
      January 01, 2010 - Research indicated that mistakes were not due to clinicians not trying hard enough; they resulted

3678. In Conversation With… David Blumenthal, MD, MPP | PSNet
      psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
      March 27, 2024 - It kept me from making mistakes. It kept me from spending money that wasn't necessary.

3679. Tool 6: How To Monitor RED Implementation and Outcomes | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool6.html
      March 01, 2025 - identify underlying trouble that increases the likelihood of problems while resisting the urge to focus on mistakes

3680. Advancing Patient Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/advancing/index.html
      July 01, 2022 - Research indicated that mistakes were not due to clinicians not trying hard enough; they resulted from