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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
December 23, 2020 - Saul Weingart, Director of the Center for Patient Safety at DFCI, to reflect on the lessons of the past
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psnet.ahrq.gov/node/49594/psn-pdf
December 01, 2009 - Over the past 40
years, the United States has come to a widely shared consensus that informed consent … Outreach workers spend months trying to develop
trusting relationships with homeless clients and even
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psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
October 01, 2017 - For the past year, the patient was receiving treatment for myasthenia gravis with intravenous immunoglobulin … does not recommend catheter exchange for the purpose of infection prevention, maintaining a PICC for months
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
January 01, 2024 - His past medical history was notable only for hypertension managed with amlodipine. … Development of a delayed chronic subdural hematoma 2 months after mild traumatic brain injury with a
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psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - and relevant financial
relationships as “financial relationships in any amount occurring within the past … 12 months that create a
conflict of interest.??? … medical records indicated he had multiple ED visits with similar
episodes of syncope in the preceding months
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psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc
June 01, 2016 - In the past, we've largely built our patient safety workforce from people who had an interest in care … For example, in the past we used to worry about handwriting errors. … The good news is that for many health care organizations, handwriting errors are now a thing of the past … During daily huddles, staff and leaders examine safety events from the past 24 hours and review quality
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - and relevant financial relationships as “financial relationships in any amount occurring within the past … 12 months that create a conflict of interest. … medical records indicated he had multiple ED visits with similar episodes of syncope in the preceding months
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psnet.ahrq.gov/node/33858/psn-pdf
May 01, 2018 - In my conversations with past and current presidential administrations, I say we should
work on a nationwide … Changing from any vendor
to any vendor has a learning curve that makes the initial 6 months hellish. … create a production system, but on
average from standards development to seeing it in the field is 18 months
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psnet.ahrq.gov/web-mm/challenging-case-multiple-suicide-attempts-complex-patient-psychiatric-comorbidities
September 27, 2023 - and relevant financial relationships as “financial relationships in any amount occurring within the past … 24 months that create a conflict of interest.
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psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
March 27, 2024 - In my conversations with past and current presidential administrations, I say we should work on a nationwide … Changing from any vendor to any vendor has a learning curve that makes the initial 6 months hellish. … create a production system, but on average from standards development to seeing it in the field is 18 months
-
psnet.ahrq.gov/node/49588/psn-pdf
August 01, 2009 - This monthly plan uses past experiences to estimate the
number of nurses needed to fully staff each
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psnet.ahrq.gov/node/49485/psn-pdf
August 29, 2024 - https://psnet.ahrq.gov/web-mm/blind-spot
The Case
A 36-year-old woman with no significant past medical … Three months after surgery, the patient still had partial visual loss.
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - related stigma can limit effective, timely care
4
Case Details (1)
• A 65-year-old woman with a past … was advised to apply ice and take ibuprofen.
5
Case Details (2)
• She returned to her PCP a few months
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psnet.ahrq.gov/node/33857/psn-pdf
July 01, 2012 - I think we will get past this issue of data entry burden. Some of it is transitional. … stakeholders of various kinds
who are looking more and more to consumer-mediated exchange as a way to get past … I was talking to one of the residents a
few months ago and the resident says, "I just got Rushakoffed
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psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
July 17, 2024 - reviewing her medical record, the admitting team noted she had been admitted 3 times in the last 2 months … suggested alternative diagnoses) and there was no history of similar possible diagnostic errors in the past
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psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
March 01, 2008 - that it makes sense to try to replicate in total what has evolved organically at Cedars-Sinai over the past … we have found that, certainly what my experience personally was, it takes somewhere between 3 to 6 months … Additionally, weeks to months would elapse before a resident could perform another similar procedure,
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psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
March 01, 2008 - Additionally, weeks to months would elapse before a resident could perform another similar procedure, … that it makes sense to try to replicate in total what has evolved organically at Cedars-Sinai over the past … we have found that, certainly what my experience personally was, it takes somewhere between 3 to 6 months
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psnet.ahrq.gov/node/33870/psn-pdf
November 01, 2018 - And is this, in fact, a nostalgic recapitulation of the past, or is this
new wine in an old bottle?
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psnet.ahrq.gov/node/49650/psn-pdf
March 01, 2012 - procedure-related complications occurring from office-based surgeries performed in Florida
over the past
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psnet.ahrq.gov/node/33659/psn-pdf
October 01, 2007 - Based on our experience over the past 6 years, let me give you examples of how
you might do this.