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Showing results for "operational".

  1. Hospital safety climate surveys: measurement issues. | PSNet

    psnet.ahrq.gov/issue/hospital-safety-climate-surveys-measurement-issues
    December 16, 2009 - Review Hospital safety climate surveys: measurement issues. Citation Text: Jackson J, Sarac C, Flin R. Hospital safety climate surveys: measurement issues. Curr Opin Crit Care. 2010;16(6):632-8. doi:10.1097/MCC.0b013e32833f0ee6. Copy Citation Format: DOI Google Scholar Pu…

  2. Identifying violation-provoking conditions in a healthcare setting. | PSNet

    psnet.ahrq.gov/issue/identifying-violation-provoking-conditions-healthcare-setting
    April 18, 2011 - Study Identifying violation-provoking conditions in a healthcare setting. Citation Text: Phipps D, Parker D, Pals EJM, et al. Identifying violation-provoking conditions in a healthcare setting. Ergonomics. 2008;51(11):1625-42. doi:10.1080/00140130802331617. Copy Citation Form…

  3. Wrong-site sinus surgery in otolaryngology. | PSNet

    psnet.ahrq.gov/issue/wrong-site-sinus-surgery-otolaryngology
    July 30, 2014 - Study Wrong-site sinus surgery in otolaryngology. Citation Text: Shah RK, Nussenbaum B, Kienstra M, et al. Wrong-site sinus surgery in otolaryngology. Otolaryngol Head Neck Surg. 2010;143(1):37-41. doi:10.1016/j.otohns.2010.04.003. Copy Citation Format: DOI Google Scholar…

  4. Understanding why quality initiatives succeed or fail: a sociotechnical systems perspective. | PSNet

    psnet.ahrq.gov/issue/understanding-why-quality-initiatives-succeed-or-fail-sociotechnical-systems-perspective
    March 10, 2021 - Commentary Understanding why quality initiatives succeed or fail: a sociotechnical systems perspective. Citation Text: Wiegmann DA. Understanding Why Quality Initiatives Succeed or Fail: A Sociotechnical Systems Perspective. Ann Surg. 2016;263(1):9-11. doi:10.1097/SLA.0000000000001333. …

  5. There is no such thing as a "nonjudgmental" debriefing: a theory and method for debriefing with good judgment. | PSNet

    psnet.ahrq.gov/issue/there-no-such-thing-nonjudgmental-debriefing-theory-and-method-debriefing-good-judgment
    December 19, 2014 - Commentary There is no such thing as a "nonjudgmental" debriefing: a theory and method for debriefing with good judgment. Citation Text: Rudolph JW, Simon R, Dufresne RL, et al. There's no such thing as "nonjudgmental" debriefing: a theory and method for debriefing with good judgment. Si…

  6. To improve health care, focus on fixing systems — not people. | PSNet

    psnet.ahrq.gov/issue/improve-health-care-focus-fixing-systems-not-people
    September 08, 2021 - Newspaper/Magazine Article To improve health care, focus on fixing systems — not people. Citation Text: Mate KS, Clark J, Salvon-Harman J. To improve health care, focus on fixing systems — not people. Harvard Business Review. July 12, 2024; Copy Citation Format: Google Scho…

  7. Perfusion safety: new initiatives and enduring principles. | PSNet

    psnet.ahrq.gov/issue/perfusion-safety-new-initiatives-and-enduring-principles
    July 19, 2023 - Commentary Perfusion safety: new initiatives and enduring principles. Citation Text: Kurusz M. Perfusion safety: new initiatives and enduring principles. Perfusion. 2011;26 Suppl 1:6-14. doi:10.1177/0267659110393389. Copy Citation Format: DOI Google Scholar PubMed BibTeX …

  8. What does nursing teamwork look like? A qualitative study. | PSNet

    psnet.ahrq.gov/issue/what-does-nursing-teamwork-look-qualitative-study
    July 02, 2014 - Study What does nursing teamwork look like? A qualitative study. Citation Text: Kalisch BJ, Weaver SJ, Salas E. What does nursing teamwork look like? A qualitative study. J Nurs Care Qual. 2009;24(4):298-307. doi:10.1097/NCQ.0b013e3181a001c0. Copy Citation Format: DOI Goo…

  9. Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. | PSNet

    psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
    June 09, 2021 - Book/Report Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. Citation Text: Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. Farnborough, UK: Healthcare Safety Investigation Branch; June 2021. Copy Citation …

  10. Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). | PSNet

    psnet.ahrq.gov/issue/safety-investigations-across-pond-deep-learning-englands-healthcare-safety-investigation
    May 03, 2023 - Newspaper/Magazine Article Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). Citation Text: Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). ISMP M…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60721/psn-pdf
    July 21, 2020 - JM: Well, I actually don’t think it’s an infrastructure issue as much as an operational issue. … Anyone can FaceTime or send a Zoom link or a WebEx link, but having that operational infrastructure

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853773/psn-pdf
    September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side The Case A first-year orthopedic surgery resident was consulted…

  13. Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx Spotlight Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the ful…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60857/psn-pdf
    August 26, 2020 - Nothing Called Small Surgery August 26, 2020 Manske C. Nothing Called Small Surgery. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/nothing-called-small-surgery The Case  A 56-year-old female presented to surgical clinic with pain and swelling in left great toe associated with progressive deformity of the …

  15. Check Twice, Transport Once | PSNet

    psnet.ahrq.gov/web-mm/check-twice-transport-once
    March 15, 2023 - Check Twice, Transport Once Citation Text: DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60745/psn-pdf
    October 01, 2020 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia July 29, 2020 Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/multiple-high-risk-events-involvi…

  17. Check the Anesthesia Machine | PSNet

    psnet.ahrq.gov/web-mm/check-anesthesia-machine
    August 01, 2006 - Check the Anesthesia Machine Citation Text: Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. 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 End…

  18. Air on the Side of Caution | PSNet

    psnet.ahrq.gov/web-mm/air-side-caution
    April 21, 2015 - Air on the Side of Caution Citation Text: Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…

  19. Feeling No Pain | PSNet

    psnet.ahrq.gov/web-mm/feeling-no-pain
    August 30, 2023 - Feeling No Pain Citation Text: Bogner MS. Feeling No Pain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72587/psn-pdf
    December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability December 23, 2020 Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm…
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