-
psnet.ahrq.gov/issue/sleep-deprivation-and-clinical-performance
February 16, 2011 - deprivation and summarize past research that suggests the impact is greatest on mood and cognitive tasks rather … than motor tasks. … clinical settings and the importance of physicians' acknowledging such states as a risk to their patients rather … than a sign of personal weakness. … Rethinking surgical safety: more than just a checklist.
-
psnet.ahrq.gov/node/35926/psn-pdf
July 26, 2010 - litigation, patient safety, and accountability from a
perspective that calls for litigation as a driver rather … than a hindrance to safety improvement. … responsibility of
safety on hospitals, which actually control the systems contributing to error far more than … , the mission to improve patient safety becomes a priority on a level that is pushed by litigation
rather … than slowed by it.
-
psnet.ahrq.gov/node/34720/psn-pdf
April 21, 2011 - evolution of systems described, arguments are made for
challenges in linking errors as a specific behavior rather … than an effect of changing work environments. … calls for
new system design approaches with greater emphasis on addressing structural deficiencies rather … than
human reliability.
-
psnet.ahrq.gov/issue/patients-right-safety-improving-quality-care-through-litigation-against-hospitals
February 17, 2011 - litigation, patient safety, and accountability from a perspective that calls for litigation as a driver rather … than a hindrance to safety improvement. … responsibility of safety on hospitals, which actually control the systems contributing to error far more than … providers, the mission to improve patient safety becomes a priority on a level that is pushed by litigation rather … than slowed by it.
-
psnet.ahrq.gov/node/34691/psn-pdf
May 18, 2016 - discusses how traditional methods of error reduction in medicine have focused on individual
performance rather … than on the systems in which individuals operate. … Rather than relying on the absence of human error, as has
been traditional in medicine, he advocates
-
psnet.ahrq.gov/issue/human-error-and-problem-causality-analysis-accidents
August 25, 2021 - evolution of systems described, arguments are made for challenges in linking errors as a specific behavior rather … than an effect of changing work environments. … calls for new system design approaches with greater emphasis on addressing structural deficiencies rather … than human reliability.
-
psnet.ahrq.gov/node/35726/psn-pdf
February 09, 2011 - deprivation and summarize past research that suggests the
impact is greatest on mood and cognitive tasks rather … than motor tasks. … clinical settings and the importance of
physicians' acknowledging such states as a risk to their patients rather … than a sign of personal weakness.
-
psnet.ahrq.gov/node/48139/psn-pdf
July 17, 2019 - investigators to approach
patients who have experienced adverse events to participate in studies, rather … than prohibit such studies
due to fear of causing further psychological harm. … discuss these
adverse events with patients through a reciprocal lens, expressing support and sympathy rather … than
maintaining an emotionally distant stance.
-
psnet.ahrq.gov/node/35611/psn-pdf
June 23, 2010 - incorporated
a negative outcome or a deviation from standard of practice into their error definition rather … than analyzing
the event independent of those factors. … of a safety culture and the need to redefine errors as
opportunities for learning and improvement rather … than individual or isolated events.
-
psnet.ahrq.gov/node/867651/psn-pdf
February 26, 2025 - Rather than reacting retrospectively to what has gone wrong, Safety II attempts
to understand the interaction … of systems and behaviors to facilitate desired outcomes rather than only
preventing undesired outcomes … Instead, Safety II simply suggests selecting events based
on frequency rather than severity. … Rather than
focusing on either end of this spectrum, a Safety II approach focuses on the middle, emphasizing … than an error or harm mitigation tool.
-
psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
October 02, 2024 - Rather than reacting retrospectively to what has gone wrong, Safety II attempts to understand the interaction … of systems and behaviors to facilitate desired outcomes rather than only preventing undesired outcomes … Instead, Safety II simply suggests selecting events based on frequency rather than severity. … Rather than focusing on either end of this spectrum, a Safety II approach focuses on the middle, emphasizing … than an error or harm mitigation tool.
-
psnet.ahrq.gov/issue/error-medicine
November 02, 2014 - discusses how traditional methods of error reduction in medicine have focused on individual performance rather … than on the systems in which individuals operate. … Rather than relying on the absence of human error, as has been traditional in medicine, he advocates
-
psnet.ahrq.gov/issue/poking-skunk-ethical-and-medico-legal-concerns-research-about-patients-experiences-medical
May 05, 2021 - permit investigators to approach patients who have experienced adverse events to participate in studies, rather … than prohibit such studies due to fear of causing further psychological harm. … discuss these adverse events with patients through a reciprocal lens, expressing support and sympathy rather … than maintaining an emotionally distant stance.
-
psnet.ahrq.gov/issue/shaping-systems-better-behavioral-choices-lessons-learned-fatal-medication-error
February 12, 2020 - Charles Denham , and Lucian Leape ) take the hospital to task for focusing on narrow improvements rather … than using complexity theory to solve underlying problems, and for creating a " second victim " by … disciplining the nurse (who was fired and ultimately criminally prosecuted) rather than acknowledging
-
psnet.ahrq.gov/node/38455/psn-pdf
January 02, 2017 - Rather than a dedicated and resource-intensive rapid response team, this hospital required
nurses to … provide a unique prototype for addressing failure to rescue initiatives that
leverage existing resources rather … than creating new ones.
-
psnet.ahrq.gov/node/43695/psn-pdf
August 02, 2015 - in malpractice claims), and administrative compensation systems (which
use an adjudication process rather … than usual courts) will all play a larger role and lead to more rapid
resolution following adverse … accountable care organizations may
lead to reform in the liability system such that organizations rather … than individuals are liable for
malpractice.
-
psnet.ahrq.gov/node/33598/psn-pdf
June 15, 2024 - More than one-third of in-hospital falls result in injury, including serious injuries such as fractures … rules for identifying high-risk
patients, but none has been shown to be significantly more accurate than … They include:
Multidisciplinary (rather than solely nursing) responsibility for intervention. … Staff and patient education (if provided by health professionals and structured rather than ad hoc). … Provision of safe footwear (rather than solely advice on safe footwear).
-
psnet.ahrq.gov/issue/error-or-act-god-study-patients-and-operating-room-team-members-perceptions-error-definition
August 10, 2011 - incorporated a negative outcome or a deviation from standard of practice into their error definition rather … than analyzing the event independent of those factors. … of a safety culture and the need to redefine errors as opportunities for learning and improvement rather … than individual or isolated events.
-
psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - safety because they
identify and address underlying system issues that have caused or could cause harm rather … than merely
addressing the immediate symptoms of a problem. … than as a genuine tool for
improvement.3 As a result, RCA was often a "check-the-box" activity, losing … than systemic improvement. … Rather than being a rigid framework,
the toolkit can be used in part or as a whole, making it highly
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.76_slideshow.ppt
October 01, 2004 - Human Factors Engineering Approach
Rely on improving design of artifacts in the world rather than relying … 25%
Mechanical vaporizer lock—prevents activating more than one vaporizer delivering a volatile … Permanently fix Christmas tree adapters to the correct flowmeter
Use clear Christmas tree adapters rather … double check the flowmeter and tubing connections
Implement engineered safety devices when possible rather … than procedural forcing functions