-
psnet.ahrq.gov/node/866158/psn-pdf
June 19, 2024 - increasing proportion of surgeries are performed in freestanding ambulatory surgery centers (ASCs)
rather … than in hospitals.
-
psnet.ahrq.gov/issue/how-common-are-cognitive-errors-cases-presented-emergency-medicine-resident-morbidity-and
May 08, 2019 - presented at one hospital's emergency medicine morbidity and mortality (M&M) conferences found that more than … When present, cognitive errors were more frequently ascribed to faulty data synthesis rather than a knowledge
-
psnet.ahrq.gov/issue/direct-oral-anticoagulant-related-medication-incidents-and-pharmacists-interventions-hospital
January 12, 2022 - While direct oral anticoagulants (DOAC) are considered safer than warfarin , DOAC-related medication … Active , rather than latent, failures contributed to most errors.
-
psnet.ahrq.gov/issue/ahrq-report-diagnostic-errors-emergency-department-wrong-answer-wrong-question
September 23, 2020 - peer-reviewed commentary asserts emergency department (ED) overcrowding is a greater safety risk than … misdiagnosis, and errors are more frequently systemic rather than cognitive.
-
psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
January 01, 2024 - multisystem illness is diagnosed can be attributed to a maladaptive emotional reaction to the
diagnosis, rather … treatment approaches generally rely on expert clinical experience
attuned to subtle atypical features rather … Psychotic presentations with atypical features lead to greater suspicion of a systemic, rather than … • Lack of personal history of schizoid
personality disorder
• Visual, olfactory, and/or tactile rather … than
auditory hallucinations
• Prominent cognitive impairment
• Concurrent motor signs
• Catatonia
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psnet.ahrq.gov/node/49667/psn-pdf
October 01, 2012 - also possible to program machines to make it impossible to
select a patient's medication from more than … Mistakes with medications occur not because a clinician has been incompetent by
making an error, but rather … is important to
acknowledge that medication errors generally occur as a result of system failures rather … than faults
produced by particular people. … Medication errors generally occur as a result of system failures rather than faults produced by
particular
-
psnet.ahrq.gov/node/35888/psn-pdf
July 23, 2010 - errors associated with continuous renal replacement therapy and found that use of
industry-prepared, rather … than manually compounded, solutions minimized errors.
-
psnet.ahrq.gov/node/37379/psn-pdf
March 28, 2012 - identifying-modifiable-barriers-medication-error-reporting-nursing-home-setting
This study suggests that organizational rather … than individual-level interventions are the key to improving
medication error reporting in nursing
-
psnet.ahrq.gov/node/37825/psn-pdf
April 11, 2011 - inherently responsible for serious patient injury and found that
outdated design and incorrect assembly, rather … than bedrails themselves, contributed to such injuries.
-
psnet.ahrq.gov/node/37564/psn-pdf
June 12, 2008 - medical-emergency-team-system-two-hospital-comparison
This study found that elderly males, patients with greater comorbid conditions, and surgical rather … than
medical patients stimulated medical emergency team activity, suggesting opportunities to further
-
psnet.ahrq.gov/node/867631/psn-pdf
February 26, 2025 - Patients whose ED note contained the word "homeless" were more likely to be
discharged rather than admitted
-
psnet.ahrq.gov/node/866590/psn-pdf
August 28, 2024 - three-
quarters of proposed risk controls outlined in the plans were weak (focusing on individual rather … than
systemic issues).
-
psnet.ahrq.gov/node/60269/psn-pdf
April 29, 2020 - extend beyond the borders of the
overlying skin changes, requiring much more extensive debridement than … the necessary but less surgically
rewarding operations (like NSTI debridement), and often work alone rather … However, rather than working together to provide a double layer of
security, this dual ‘ownership’ resulted … important, that will ultimately lead to a culture of safety,
where doing the safe thing feels natural, rather … than enforced, thus augmenting rather than diminishing
physician autonomy.13
Take-Home Points
Necrotizing
-
psnet.ahrq.gov/node/34758/psn-pdf
January 29, 2019 - https://psnet.ahrq.gov/issue/normal-accidents-living-high-risk-technologies
Though less often cited than … tight coupling" as the two factors that create an environment in which a major accident becomes more
rather … than less probable over time, regardless of steps taken to increase safety.
-
psnet.ahrq.gov/node/42229/psn-pdf
July 03, 2014 - Analysis of more than
30,000 surgical procedures revealed that hospitals received significantly greater … findings of this study arise directly
from a payment system that rewards providers for the volume rather … than the quality of service provided.
-
psnet.ahrq.gov/node/37242/psn-pdf
September 12, 2016 - The authors conclude that the original definition, which uses all
deaths rather than specific complications
-
psnet.ahrq.gov/node/39973/psn-pdf
January 04, 2011 - Examining the evidence on ACGME duty hour standards and patient outcomes, this commentary suggests
that rather … than implementing one policy at a time, alternative approaches should be assessed to
effectively improve
-
psnet.ahrq.gov/node/40909/psn-pdf
November 09, 2011 - handing-over-patient-care-it-just-old-broken-telephone-game
General surgery residents strongly preferred signing out patients in person rather … than by
videoconferencing or other electronic modalities, but in this simulation study, signout accuracy
-
psnet.ahrq.gov/node/37518/psn-pdf
March 13, 2008 - innovation-patient-safety-new-task-design-reducing-patient-falls
This study describes the success of using the prone position, rather … than sitting-standing, when helping
patients transfer out of bed to prevent falls.
-
psnet.ahrq.gov/node/37725/psn-pdf
February 17, 2011 - issues such as copying
and pasting portions of clinical notes and requirements to fill in templates rather … than interact meaningfully
with patients.