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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/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/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/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/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/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/node/72837/psn-pdf
September 01, 2022 - Further, data has demonstrated that patients with an SUD during their pregnancy have worse
outcomes than … mentoring needs.4 Critically, peer recovery
mentors are not traditional community health workers, but rather … In recent years, the program has focused resources on patient care rather than on data collection. … The program has
succeeded in increasing the likelihood that patients will have more than seven prenatal
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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-barbara-drew-rn-phd
May 01, 2016 - had an average census of 66 patients per day during those 31 days, and we captured a total of more than … And then have the monitor behave differently if you're a novice than if you're an expert. … BD : Alarm fatigue is probably a much bigger problem on a general medical floor than in the ICU. … overcome alarm and alert fatigue have aimed to increase the value of the information of each alarm, rather … than adding simply more alarms.( 16 ) Increasing the value of the information requires a decrease in
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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/node/865454/psn-pdf
March 27, 2024 - Psychologically safe cultures focus more on learning and how system failures lead to safety events rather … than on individual actions. … For example, someone who is extroverted may be more likely to speak up
than someone who is introverted … SOPS
Nursing Home Survey respondents) and found that LPNs rated all measures of safety culture lower than … This survey also found that LPNs working in nursing homes were less satisfied with their jobs than LPNs
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - For example, in this case, it is known that, despite maximal medical therapy, more than 95% of patients … the lethal diagnosis, the patient might choose to spend more time with his family in the coming year than … particular diagnosis, as is practically the entire scientific evidence base of modern medicine (other than … solutions must directly address this root cause.( 1 ) Classifying diagnostic errors by clinical context rather … than by cognitive bias might offer opportunities to develop systems solutions to cognitive problems
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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
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psnet.ahrq.gov/node/49587/psn-pdf
May 01, 2009 - Rather
acutely, the patient became pulseless, and CPR was initiated as the patient's cardiac rhythm … More than 1 million physicians worldwide have taken an ATLS course. … wounds are lower, and for the rare patient with blunt trauma–induced cardiac rupture,
even lower (less than … the epidemiology, prevention, and amelioration of trauma: the
transition to approaches etiologically rather … than descriptively based. 1968.
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psnet.ahrq.gov/node/49734/psn-pdf
May 01, 2015 - Upon arrival in the emergency
department (ED), his pH was less than 6.8, carbon dioxide 37 mm Hg, oxygen … so, his matrix helped us realize that
seatbelts and airbags are, in aggregate, far more beneficial than … those expressed by end-users (the
proceduralists themselves) in qualitative studies and provide us a rather … the epidemiology, prevention, and amelioration of trauma: the
transition to approaches etiologically rather … than descriptively based. 1968.
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psnet.ahrq.gov/web-mm/electronic-err
April 01, 2014 - The nurse informed him that the patient had developed a junctional rhythm with a heart rate less than … been given 100 mg of metoprolol XL and 180 mg of diltiazem CR by the hospital admitting physician, rather … than the 50 mg of metoprolol XL and no diltiazem intended by her outpatient cardiologist. … flag to medication and problem lists indicating that the patient has been seen in clinic more recently than … of clinical information, it is important not to abandon the safety practices used in the past, but rather