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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - Two key theoretical constructs are helpful in beginning to answer this question: dual process theory … underresourced, and dominated by antiquated hierarchies that may inhibit the free exchange of ideas, fail to question … Teamwork is most effective when all members of the team feel a sense of psychological safety to question … Systems should consider methods to highlight potentially contradictory information and question whether
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psnet.ahrq.gov/node/33828/psn-pdf
March 01, 2017 - MDW: That's a great question. … MDW: Another great question. We've not always followed this through to the end. … It is the key question. I'm sick of
things that work once. … RW: I guess the question going forward is the same scaling question. … My big
question is: how do we make it practical and useful so it helps patients?
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psnet.ahrq.gov/node/43287/psn-pdf
July 02, 2014 - lessons-aftermath-incident
The effectiveness of root cause analysis (RCA) as a safety improvement tool has been called into question
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psnet.ahrq.gov/issue/patient-handoffs-0
November 23, 2024 - Improving Diagnostic Safety and Quality
April 26, 2023
Listening and question-asking
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psnet.ahrq.gov/issue/making-healthcare-safer-understanding-designing-and-buying-better-it
February 20, 2019 - unrecognized due to insufficient reporting and the tendency to place blame on the user rather than question
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psnet.ahrq.gov/issue/venous-thromboembolism-after-trauma-never-event
January 12, 2022 - postoperative venous thromboembolism despite use of appropriate prophylactic measures, calling into question
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psnet.ahrq.gov/issue/race-differences-reported-harmful-patient-safety-events-healthcare-system-high-reliability
March 01, 2023 - The authors raise the question of whether reporting bias by race occurs in patient safety reporting and
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psnet.ahrq.gov/issue/poor-resident-attending-intraoperative-communication-may-compromise-patient-safety
September 23, 2020 - While surgical attending physicians reported encouraging residents to question their intraoperative decisions
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psnet.ahrq.gov/issue/nursing-2006-patient-safety-survey-report
March 01, 2023 - They provide a short discussion on the results for each question.
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psnet.ahrq.gov/issue/neonatal-near-miss-audits-systematic-review-and-call-action
August 04, 2021 - morbidity and mortality, underscoring the need for well-designed, ethical studies examining this research question
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psnet.ahrq.gov/issue/medication-administration-aged-care-facilities-mixed-methods-systematic-review-0
July 31, 2024 - This activity calls into question resident autonomy to decline medications as well as safety for medications
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psnet.ahrq.gov/issue/how-might-acknowledging-medical-error-promote-patient-safety
July 29, 2015 - The authors present a case of diagnostic error and use a question-and-answer format to review how to
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psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
May 01, 2019 - Every EMS system handles this exact question differently. For some systems, it's protocol-driven. … We don't stop to think or to ask the question "What would this patient want me to do?" … But if EMS isn't asking the question, then it will never be answered. … or two or three people who are available to ask the question while still trying to save the patient's … If they don't know the answer to the question, you're not going to be able to sort that out on scene.
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psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph
May 01, 2019 - Every EMS system handles this exact question differently. For some systems, it's protocol-driven. … We don't stop to think or to ask the question "What would this patient want me to do?" … But if EMS isn't asking the question, then it will never be answered. … or two or three people who are available to ask the question while still trying to save the patient's … If they don't know the answer to the question, you're not going to be able to sort that out on scene.
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psnet.ahrq.gov/node/40807/psn-pdf
September 01, 2016 - The hospital in question did not have
a barcoding medication administration system.
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psnet.ahrq.gov/node/39106/psn-pdf
June 30, 2011 - In particular, the authority
gradient resulted in residents feeling unable to question senior physicians
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psnet.ahrq.gov/node/40841/psn-pdf
October 16, 2012 - This study uses econometric
techniques to address a related but distinct question: what is the daily
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psnet.ahrq.gov/node/46169/psn-pdf
June 07, 2017 - Other studies
have also called into question the methodology behind the star rating system.
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psnet.ahrq.gov/node/40993/psn-pdf
December 14, 2011 - incidence of
transcription errors in this study is especially surprising given that the hospital in question
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psnet.ahrq.gov/issue/physicians-responses-clinical-decision-support-intensive-care-unit-comparison-four-different
February 14, 2024 - within electronic health records to avert safety problems while avoiding alert fatigue is an ongoing question