-
psnet.ahrq.gov/issue/health-factory
December 23, 2008 - organizations approach error the way other industries do, by constantly evaluating and solving problems, rather … than working around them.
-
psnet.ahrq.gov/node/34715/psn-pdf
February 18, 2011 - the theory of continuous improvement, calls for understanding and revision of the
production process rather … than placing blame on the individual.
-
psnet.ahrq.gov/node/844044/psn-pdf
January 01, 2024 - the same specialty, it may be contextual factors (i.e., referral type)
that affect diagnostic errors rather … than specialty.
-
psnet.ahrq.gov/issue/preventable-anesthesia-related-adverse-events-large-tertiary-care-center-nine-year
November 12, 2014 - were either respiratory complications or patient injuries, and they were largely due to systems issues rather … than individual clinician performance. … 2015
A facilitated survey instrument captures significantly more anesthesia events than
-
psnet.ahrq.gov/issue/avoid-punitive-approach-your-safety-event-reporting
October 23, 2019 - importance of staff education and leadership to support the focus of reporting initiatives on the system rather … than individuals when failures occur.
-
psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
June 16, 2021 - 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 … it 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/38706/psn-pdf
June 17, 2009 - tool, they discovered that only nine of the triggers generated a positive
predictive value of greater than … advocate for use of their trigger approach
but perhaps focusing only on the nine high-yield triggers rather … than the exhaustive list.
-
psnet.ahrq.gov/node/47506/psn-pdf
January 21, 2019 - balance: day shift had better scores compared to night shift, and shorter shifts had better scores
than … The authors suggest that burnout interventions target work settings rather than
individuals, because
-
psnet.ahrq.gov/node/39620/psn-pdf
September 20, 2011 - Although past research
suggests that patient complaints relate more to service quality rather than quality … likelihood to recommend" a hospital had strong associations with technical performance measures in more
than
-
psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
September 20, 2011 - this patient had a psychiatric disorder, many physical symptoms were then ascribed to that disorder rather … than to a concurrent or underlying medical illness. … New medical symptoms in psychiatric patients should be listed as separate problems rather than being … Psychiatric patients whose symptoms are worsening rather than improving with treatment warrant careful … Paranoid psychosis in old age: much more common than previously thought?
-
psnet.ahrq.gov/node/43990/psn-pdf
April 22, 2015 - This qualitative study found that clinicians generally prefer to fix and forget safety problems
rather … than report them.
-
psnet.ahrq.gov/node/34812/psn-pdf
March 05, 2008 - critical-incident-technique
This review details the background of a methodology aimed to record specific behaviors, rather … than
opinions or estimates, in evaluating a given activity.
-
psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
March 31, 2021 - 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/37912/psn-pdf
September 25, 2008 - However,
use of the application itself may only be a marker rather than a direct cause of a hospital's
-
psnet.ahrq.gov/node/47284/psn-pdf
December 05, 2018 - either respiratory
complications or patient injuries, and they were largely due to systems issues rather … than individual
clinician performance.
-
psnet.ahrq.gov/node/46862/psn-pdf
February 21, 2018 - ensure-patient-safety
Traditionally, efforts to reduce medical errors have focused on modifying individual behavior rather … than
systems.
-
psnet.ahrq.gov/node/44199/psn-pdf
September 09, 2015 - to call a nurse for help, they were more
willing to ask for help if encouraged to do so by a doctor rather … than a nurse.
-
psnet.ahrq.gov/node/42138/psn-pdf
March 27, 2013 - setting, although the majority of these errors appear to be administering drugs at the wrong time
rather … than administering the wrong dose or wrong medication entirely.
-
psnet.ahrq.gov/node/47495/psn-pdf
October 31, 2018 - review found that most leadership training in maternity settings used a work-based learning
approach rather … than simulation or classroom interventions.
-
psnet.ahrq.gov/node/44950/psn-pdf
March 02, 2016 - affect the care plan, were more often identified when providers specifically elicited such information rather … than when it arose spontaneously.