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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/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/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
June 30, 2021 - It enabled the public health and healthcare system to control hospital patient flow, rather than inundating … will have to focus on the ED and possibly the separation of spaces for contagious patients, more so than … Other than that, I think that healthcare facilities, more than any other kind of building type, have … Having more alcohol-based hand rubs, having sinks in the room, those are going to be more important than … The building can be so much more intelligent than it is right now.
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psnet.ahrq.gov/perspective/covid-19-and-built-environment
June 30, 2021 - It enabled the public health and healthcare system to control hospital patient flow, rather than inundating … will have to focus on the ED and possibly the separation of spaces for contagious patients, more so than … Other than that, I think that healthcare facilities, more than any other kind of building type, have … Having more alcohol-based hand rubs, having sinks in the room, those are going to be more important than … The building can be so much more intelligent than it is right now.
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psnet.ahrq.gov/web-mm/reconciling-records
September 01, 2017 - family had given incorrect data to the ED staff (including listing the patient as being on prednisolone rather … than prednisone), and the physicians caring for the patient had simply checked off the option to continue
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psnet.ahrq.gov/node/49817/psn-pdf
January 01, 2018 - receiving a single, full day's dose of metoprolol as the immediate-release formulation (tartrate) rather … than
the intended extended-release formulation (succinate).
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psnet.ahrq.gov/node/838972/psn-pdf
October 27, 2022 - Rather than admitting guilt or taking sole responsibility for the conflict, an apology can
convey a
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psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient
July 19, 2023 - antipsychotics, especially when done abruptly, is associated with higher rates of relapse to psychosis.( 10 ) Rather … than simply a recurrence of illness, this iatrogenic effect has been thought to be a "supersensitivity
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psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - This affects more than 100,000 house staff in the United States (3) and 32,000 in
Europe (4) and leads … intern in the ICU made significant errors, ones that did not seem to stem from inadequate
knowledge but rather
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psnet.ahrq.gov/node/60542/psn-pdf
May 27, 2020 - mEq/100 mL,
a ten-fold higher concentration than intended. … Rather,
the safety process often relied on a dietician to notify the team if the TPN had not been ordered … order sets should be standardized to include a uniform bag size of 250 mL for patients
who weigh less than … or equal to 10 kg and 500 mL for patients who weigh greater than 10 kg.
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psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
September 18, 2024 - Over this period, his heart rate increased to greater than 120 bpm and his blood pressure was 175/95 … common chief complaint and diagnosis in United States emergency departments (EDs), accounting for more than … Making a diagnosis often involves shades of gray, rather than black and white data points.
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psnet.ahrq.gov/web-mm/deciphering-code
November 16, 2022 - However, IT systems should be viewed as tools rather than solutions.
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psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
January 24, 2018 - In fact, studies of multiple industries show that workarounds are inevitable, which means that rather … than trying to ban them, it may be more valuable to develop preemptive strategies to promote their safe
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psnet.ahrq.gov/node/33820/psn-pdf
December 01, 2016 - While that sounds kind of squishy, I can tell you that,
after literally more than a million submissions … Rather, we often see
that leaders feel like it's necessary to throw somebody to the wolves to show that
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psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
May 16, 2022 - It was recognized soon after the surgery that the ICG had been prepared using 50% dextrose, rather than … harm and longer hospital stays but can be very expensive, with reports of costing the US economy more than … Rethinking surgical safety: more than just a checklist.
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
January 01, 2023 - • Less than 10% of the parent compound is excreted unchanged in the urine,
and toxicity can occur … Relaxants) (2)
• Baclofen is often prescribed for spasticity and musculoskeletal pain,18 but
more than … • However, these data may not exist, may be out of date, may identify acute
kidney disease rather … than chronic disease, and may not identify all dialysis
patients—potentially leading to inappropriate
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - The metabolic panel was normal except for borderline elevation of serum creatinine, higher than his baseline … “High-risk” abdominal pain is characterized by clinical features including age greater than 65 years, … while also improving resource utilization and decreasing costs to the health system. 23
In this case, rather … than discharging the patient with a questionable diagnosis and unresolved pain, the clinician could
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psnet.ahrq.gov/node/33726/psn-pdf
March 01, 2012 - crown jewel of our democracy, but we've perverted the purposes and
created this as a first resort rather … than the last resort it's intended to be. … by the
number of cases that we have concluded our care was reasonable versus not; before 2001, more than … RB: Well, it's actually fascinating and I am more invigorated than ever over this.
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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