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Total Results: 7,926 records

Showing results for "mistakes".

  1. Final Progress Report: Effects of Extended Work Hours on ICU Patient Safety (pdf file)

    www.ahrq.gov/sites/default/files/2024-09/czeisler-report.pdf
    January 01, 2024 - causes of adverse events were medication use, wound infections, operative complications, and diagnostic mistakes

  2. Strategy 3: Bedside Shift Report (Tool 3)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/strat3_tool_3_pres_video_508.pptx
    July 23, 2010 - Patient safety: Potential mistakes are caught early in shift change and delays in tests or admission

  3. Key Lessons from the National Evaluation of the CHIPRA Quality Demonstration Grant Program (pdf file)

    www.ahrq.gov/sites/default/files/publications/files/finalsummary.pdf
    February 21, 2016 - CHIPRA Quality Demonstration Grant Program – Apply lessons learned from each other to avoid repeating mistakes

  4. Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program (pdf file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
    January 01, 2005 - Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program 223 Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program Marilyn Flack, Terrie Reed, Jay Crowley, Susan Gardner Abstract The U.S. Food and…

  5. 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive in a Single Hospital? (pdf file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meliones_40.pdf
    January 01, 2006 - 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive in a Single Hospital? 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive …

  6. Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
    January 01, 2005 - Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program 223 Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program Marilyn Flack, Terrie Reed, Jay Crowley, Susan Gardner Abstract The U.S. Food and…

  7. 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive in a Single Hospital? (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meliones_40.pdf
    January 01, 2006 - 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive in a Single Hospital? 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive …

  8. A framework for assessing reasoning about controversial end-of-life clinical decisions. | PSNet

    psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
    November 30, 2023 - A framework for assessing reasoning about controversial end-of-life clinical decisions. Citation Text: Fedyk M, Fairman N, Romano PS, et al. A framework for assessing reasoning about controversial end-of-life clinical decisions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality…

  9. In Conversation with…Jack Barker, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-withjack-barker-phd
    January 01, 2006 - In Conversation with…Jack Barker, PhD January 1, 2006  Also Read an Essay Citation Text: In Conversation with…Jack Barker, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy C…

  10. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
    August 01, 2022 - System-Focused Event Investigation and Analysis Guide AHRQ Communication and Optimal Resolution Toolkit Purpose : To help teams adopt a system-focused approached to event investigation and analysis. Who should use this tool? Event Reporting, Investigation, and Analysis Team. How to use this tool : Review…

  11. In Conversation With... Barbara Drew, RN, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
    May 01, 2016 - In Conversation With... Barbara Drew, RN, PhD May 1, 2016  Also Read an Essay Citation Text: In Conversation With.. Barbara Drew, RN, PhD. PSNet [internet]. 2016.In Conversation With... Barbara Drew, RN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare…

  12. Optimize Briefings and Debriefings: Facilitator Notes | Agency for Healthcare Research and Quality

    ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-fac-notes.html
    December 01, 2017 - Previously, mistakes might be uncovered after the case’s conclusion when the team had dispersed.

  13. SOPS™ ASC Webcast Transcript (pdf file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops-asc-webcast-transcript-ad.pdf
    February 01, 2019 - Famolaro, Slide 18 [Describer: Communication Openness: 85% Response to Mistakes: 82% Staff Training

  14. Common Cause Analysis: Focus on Institutional Change (pdf file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdf
    January 20, 2008 - They include slips, lapses, mistakes, etc.

  15. In Conversation With... Michael L. Millenson | PSNet

    psnet.ahrq.gov/perspective/conversation-michael-l-millenson
    April 27, 2022 - often-cited sound bite from the 1994 article published by Lucian Leape that the death toll from medical mistakes

  16. The Media’s Role in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/medias-role-patient-safety
    April 27, 2022 - often-cited sound bite from the 1994 article published by Lucian Leape that the death toll from medical mistakes

  17. In Conversation With... Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA | PSNet

    psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
    June 30, 2021 - The mistakes and the struggles behind America’s coronavirus tragedy.

  18. Patient Safety During Hospital Discharge | PSNet

    psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
    April 01, 2018 - June 13, 2011 Learning from mistakes: factors that influence how students and residents

  19. COVID-19 and the Built Environment | PSNet

    psnet.ahrq.gov/perspective/covid-19-and-built-environment
    June 30, 2021 - The mistakes and the struggles behind America’s coronavirus tragedy.

  20. Common Cause Analysis: Focus on Institutional Change (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdf
    January 20, 2008 - They include slips, lapses, mistakes, etc.
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