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psnet.ahrq.gov/perspective/building-capacity-patient-safety
July 31, 2023 - Healthcare organizations can improve reporting by focusing reports on patient harms rather than requiring … when we start looking across the whole system, that’s when we realize that these are bigger problems than … Other than the quick turnaround, our data science and research teams conduct analyses on the information … We have had more than 90,000 attendees to date at our local, regional, statewide, and virtual education … Our system is not perfect by any means, but it is robust and farther along than most.
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psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
July 31, 2023 - when we start looking across the whole system, that’s when we realize that these are bigger problems than … Other than the quick turnaround, our data science and research teams conduct analyses on the information … We have had more than 90,000 attendees to date at our local, regional, statewide, and virtual education … Our system is not perfect by any means, but it is robust and farther along than most. … Healthcare organizations can improve reporting by focusing reports on patient harms rather than requiring
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
March 24, 2025 - second victim and the main theme of the IOM report, which was that most errors are system problems rather … than people problems? … Most people look for internal support first from peers, and probably more people than any talk to family
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psnet.ahrq.gov/node/836885/psn-pdf
May 16, 2022 - acutely altered mental status, therapies
such as atropine or transcutaneous pacing should be initiated.1 Rather … than following the algorithm, focus
was instead diverted to the patient’s neurologic symptoms and ACLS … Use of a treadmill may be safer than having the patient walk up three flights of steps, as
stairwells
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - reported that non-Hispanic Black women
were 2.6 times more likely to have a pregnancy-related death than … obstetric hemorrhage, non-Hispanic Black and Hispanic women are 4.7 and 3.7 times
more likely to die than … respectively, in one large American state.18 These staggering
disparities cannot be explained by race, but rather
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psnet.ahrq.gov/node/50611/psn-pdf
October 30, 2019 - and complexities in oral anticoagulation with warfarin (Coumadin) and may be easier and
safer to use than … abdominal surgery is at high risk, and guidelines suggest starting prophylaxis for such
patients.(20) Rather … than just thinking about "starting packs," we should also consider "starting lacks" that
might have
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psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - None of the notes or clinical documentation from the referring hospital arrived with the patient other than … In fact, non-emergent transfers may be more common than those of critically ill patients, as up to 90% … This in itself is unlikely to have affected the treatment of the patient; rather, the lack of information
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psnet.ahrq.gov/node/49579/psn-pdf
March 21, 2009 - This process should last no longer than a few minutes and normally takes place in the form of a
brief … community-acquired pneumonia vs. pulmonary embolism, etc.") rather than labeling the patient with a
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psnet.ahrq.gov/web-mm/lost-transition
November 17, 2010 - opportunity for rescue and a threat to safety.( 2,3 ) Most health care teams now consist of far more than … all the findings were considered in light of the diagnosis of “urinary tract infection and anemia,” rather … than reconsidering the new information as it came in.( 13 ) In this way, the case illustrated Canadian
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - Another advantage of elective oophorectomy is a 27% reduction in risk of breast cancer in women younger than … not removed during the hysterectomy and assumed that the fluid-containing structure was an abscess rather … than an ovary, given the history of previous abscess.
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psnet.ahrq.gov/node/846915/psn-pdf
March 29, 2023 - experience “mood swings” of emotional disruption and acting out behavior for briefer periods of time than … Hamilton Depression Inventory, PHQ-9) can help to attribute mood symptoms to
depressive disorder, rather … than to the associated borderline personality disorder.
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psnet.ahrq.gov/node/49675/psn-pdf
February 01, 2013 - When she could not be
contacted the first day by phone, a letter should have been sent then, rather … than 11 days later. … Obtain or verify contact information, preferably including more than one contact method, each time a
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psnet.ahrq.gov/node/74691/psn-pdf
January 01, 2021 - bcm.edu
Context of the Innovation
Wrong or delayed diagnoses cause more serious harms to patients than … reviewers with opportunity for discussion to fine-tune findings
Evaluation of the diagnostic process rather … than the patient outcome
Evaluation of context to explain different perspectives and account for evolution
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psnet.ahrq.gov/node/72689/psn-pdf
January 29, 2021 - workflow which are punctuated by pages, texts, and calls have vastly increased
and are more frequent than … that state that a new fever
in a patient in the ICU “should trigger a careful clinical assessment rather … than automatic orders for
laboratory or radiologic tests.”9 The reflexive ordering of tests without
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - pneumothorax rates remain around 3%, suggesting that target location and characteristics affect risk more than … Rather, it demonstrates a common scenario in which a busy medical team hands off or turns over care to … interface has been shown to have higher sensitivity and specificity for the diagnosis of pneumothorax than
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psnet.ahrq.gov/web-mm/elopement
July 14, 2010 - adverse events and includes death or serious harm associated with elopement (disappearance) for more than … have been missing for a significant period of time, most typically 4 hours, are typically readmitted rather … than just returned to their unit.
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - reasoning: we often consider a patient’s presentation as a problem to be solved at one point in time, rather … than a recurring and evolving problem that is influenced by ongoing changes in a patient’s health. … effect: the patient lost a significant amount of weight, although the rate of weight loss was more than
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psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
January 01, 2018 - Singh and colleagues identified 190 diagnostic errors.( 6 ) Expert review determined that more than 35% … and pasted lifestyle counseling in patients with diabetes was less effective in controlling glucose than … outcomes, cannot be underestimated, as it may allow the note to be used more for clinical communication rather … than for billing or coding, thereby freeing the provider from the perceived need to include extraneous … I'm more optimistic about physical exam skills than I am about note-writing skills.
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psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
May 01, 2007 - , the history of quality and safety in the National Health Service (NHS) until recently has been a "rather … Rather, they concerned incompetent or poorly performing doctors, whose colleagues were covering up for … you expected and what has been harder than you expected? … In the UK, when you're trying to introduce change, you rather feel that you're in a goldfish bowl. … RW: What's been harder than you thought?
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psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
May 01, 2007 - Rather, they concerned incompetent or poorly performing doctors, whose colleagues were covering up for … you expected and what has been harder than you expected? … In the UK, when you're trying to introduce change, you rather feel that you're in a goldfish bowl. … RW: What's been harder than you thought? … , the history of quality and safety in the National Health Service (NHS) until recently has been a "rather