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Showing results for "operations".

  1. Towards a framework for managing risk associated with technology-induced error. | PSNet

    psnet.ahrq.gov/issue/towards-framework-managing-risk-associated-technology-induced-error
    May 10, 2013 - Commentary Towards a framework for managing risk associated with technology-induced error. Citation Text: Borycki EM, Kushniruk AW. Towards a Framework for Managing Risk Associated with Technology-Induced Error. Stud Health Technol Inform. 2017;234:42-48. Copy Citation Format: …

  2. Monitoring Fetal Health | PSNet

    psnet.ahrq.gov/web-mm/monitoring-fetal-health
    September 08, 2010 - These methods have been applied in other high-risk domains (e.g., aviation, processing plant operations

  3. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety | PSNet

    psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
    March 01, 2017 - Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety Sara J. Singer, MBA, PhD | March 1, 2017  Also Read a Conversation View more articles from the same authors. Citation Text: Singer SJ. Our Maturing Understanding of Safety C…

  4. In Conversation With… Eduardo Salas, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
    November 01, 2011 - In Conversation With… Eduardo Salas, PhD November 1, 2011  Also Read an Essay Citation Text: In Conversation With… Eduardo Salas, PhD . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.…

  5. First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit | PSNet

    psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
    October 30, 2019 - First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit Jochen Profit, MD, MPH; Annette Scheid, MD; and Erick Ridout, MD | October 30, 2019  Also Read the Conversation View more articles from the same authors. Citation Text: Profit J, …

  6. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? | PSNet

    psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
    March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? Citation Text: Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. C…

  7. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
    January 01, 2022 - Spotlight Spotlight Patient Safety Events Involving Opioid Dose Stacking Source and Credits • This presentation is based on the January 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73103/psn-pdf
    March 31, 2021 - Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination March 31, 2021 Valdes W, Utter GH. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-…

  9. 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 - SPOTLIGHT CASE When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Citation Text: Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…

  10. Death by PCA | PSNet

    psnet.ahrq.gov/web-mm/death-pca
    January 06, 2017 - Death by PCA Citation Text: Hicks RW. Death by PCA. 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 Endnote tagged PubMedId RIS Dow…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73642/psn-pdf
    August 25, 2021 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected August 25, 2021 Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect- unexpected …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49855/psn-pdf
    March 01, 2019 - Which Line: Ordering Provider or Proceduralist? March 1, 2019 Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist Case Objectives Review the role of mistake-proofing to block errors from leading to adverse…

  13. Annual Perspective: Psychological Safety of Healthcare Staff | PSNet

    psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
    November 16, 2022 - Annual Perspective Annual Perspective: Psychological Safety of Healthcare Staff March 31, 2022  View more articles from the same authors. Citation Text: Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. P…

  14. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. | PSNet

    psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
    March 15, 2023 - SPOTLIGHT CASE False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. Citation Text: Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …

  15. Abdominal Pain in Early Pregnancy | PSNet

    psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy
    November 13, 2024 - SPOTLIGHT CASE Abdominal Pain in Early Pregnancy Citation Text: Kilpatrick CC. Abdominal Pain in Early Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibT…

  16. In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles | PSNet

    psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
    August 28, 2024 - the ability of a system to adjust its functioning prior to, during, or following events to sustain operations

  17. Application of Safety-II Principles | PSNet

    psnet.ahrq.gov/perspective/application-safety-ii-principles
    August 28, 2024 - the ability of a system to adjust its functioning prior to, during, or following events to sustain operations

  18. Learning from lawsuits: using malpractice claims data to develop care transitions planning tools. | PSNet

    psnet.ahrq.gov/issue/learning-lawsuits-using-malpractice-claims-data-develop-care-transitions-planning-tools
    January 21, 2019 - Study Learning from lawsuits: using malpractice claims data to develop care transitions planning tools. Citation Text: Arbaje AI, Werner NE, Kasda EM, et al. Learning From Lawsuits: Using Malpractice Claims Data to Develop Care Transitions Planning Tools. J Patient Saf. 2020;16(1):52-57.…

  19. A virtual breakthrough series collaborative for missed test results: a stepped-wedge cluster-randomized clinical trial. | PSNet

    psnet.ahrq.gov/issue/virtual-breakthrough-series-collaborative-missed-test-results-stepped-wedge-cluster
    May 12, 2021 - Study A virtual breakthrough series collaborative for missed test results: a stepped-wedge cluster-randomized clinical trial. Citation Text: Zubkoff L, Zimolzak AJ, Meyer AND, et al. A virtual breakthrough series collaborative for missed test results: a stepped-wedge cluster-randomized c…

  20. Application of human factors methods to understand missed follow-up of abnormal test results. | PSNet

    psnet.ahrq.gov/issue/application-human-factors-methods-understand-missed-follow-abnormal-test-results
    December 16, 2020 - Study Application of human factors methods to understand missed follow-up of abnormal test results. Citation Text: Rogith D, Satterly T, Singh H, et al. Application of human factors methods to understand missed follow-up of abnormal test results. Appl Clin Inform. 2020;11(05):692-698. do…
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