-
psnet.ahrq.gov/node/35365/psn-pdf
February 17, 2011 - research to disseminate
quality improvement, greater adoption of safety efforts as a part of quality rather … than a competitor of it, and
ongoing appreciation of what outside industries can bring to health care
-
psnet.ahrq.gov/node/45924/psn-pdf
March 15, 2017 - events were judged to be preventable, and incidents were frequently due to
the organization of care rather … than from knowledge gaps on the part of physicians.
-
psnet.ahrq.gov/node/41561/psn-pdf
August 01, 2012 - investigators concluded that the low rate of reporting
was likely due to hospital failure to identify events rather … than hospitals failing to report known events.
-
psnet.ahrq.gov/node/44344/psn-pdf
July 22, 2015 - can remain unrecognized due to insufficient reporting and the
tendency to place blame on the user rather … than question whether the equipment functioned appropriately.
-
psnet.ahrq.gov/node/41607/psn-pdf
January 03, 2017 - issue/using-risk-assessment-approach-determine-which-factors-influence-whether-
partially-bilingual
Rather … than using professional interpreters, many partially bilingual clinicians rely on their own (sometimes
-
psnet.ahrq.gov/node/39199/psn-pdf
January 28, 2010 - Rather than relying on specific vital sign abnormalities, nurses
relied on a combination of clinical
-
psnet.ahrq.gov/node/43068/psn-pdf
May 29, 2014 - error of omission) were the most common concerns, often related to patient or family caregiver
actions rather … than the home hospice team.
-
psnet.ahrq.gov/node/35332/psn-pdf
September 21, 2005 - between language
barriers and adverse events, the study design only offers an associative relationship rather … than a
causative one.
-
psnet.ahrq.gov/issue/effect-bedrails-falls-and-injury-systematic-review-clinical-studies
March 15, 2016 - inherently responsible for serious patient injury and found that outdated design and incorrect assembly, rather … than bedrails themselves, contributed to such injuries. … 'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than
-
psnet.ahrq.gov/node/49752/psn-pdf
January 01, 2016 - white, which was abnormal for acetic acid, and
that led to the discovery that TCA had been applied rather … than acetic acid. … vaginal mucosa or the labia, and after the sodium
bicarbonate treatment the white area was smaller than … used intervention in the TCA
chemical peel consists of the application of cold water as a diluent, rather … than a neutralizer.
-
psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
February 26, 2025 - The idea was rather than just invite patients to read their notes passively, we ask them to actively … It also offloads the clinicians, because the messages come through a central mechanism rather than going … You've done some work on collaborative note-writing rather than the provider's note being the note of … Rather than have doctors solely responsible for the note, what about making it collaborative? … A resident once likened OpenNotes to bedside rounding: rather than spend a minute in the room with the
-
psnet.ahrq.gov/issue/frequency-pediatric-medication-administration-errors-and-contributing-factors
November 16, 2022 - The authors argue that their findings reinforce the need to adopt a systems approach to prevention rather … than focusing solely on individual nursing practice.
-
psnet.ahrq.gov/issue/analysis-major-errors-and-equipment-failures-anesthesia-management-considerations-prevention
May 27, 2011 - The authors describe characteristics from more than 1000 incidents collected and offer strategies to … authors conclude that it may be beneficial to classify specific incidents by a preventive strategy, rather … than one based on outcomes, in order to prevent future adverse events and provide more constructive
-
psnet.ahrq.gov/issue/normal-accidents-living-high-risk-technologies
March 06, 2005 - Though less often cited than high-reliability theory in the health care literature, normal accidents … 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/issue/challenger-launch-decision-risky-technology-culture-and-deviance-nasa
November 18, 2015 - Vaughan identifies two general causes other than pressures related to the timeline: a dispersion of knowledge … groups to the possibility of serious error are cast as consistent with a prevailing belief or strategy, rather … than interpreted as grounds for casting it aside.
-
psnet.ahrq.gov/issue/safety-i-and-safety-ii-past-and-future-safety-management
July 22, 2019 - Historically, the approach to patient safety has been more reactive rather than proactive, involving
-
psnet.ahrq.gov/node/49818/psn-pdf
January 01, 2018 - patient did not know to inform the
insurance company that the colonoscopy was for screening purposes (rather … than diagnostic purposes, as
initially coded by the primary care physician) and that the copayment … For instance, rather
absurdly, if an abnormality (such as a polyp or growth) is found during a colonoscopy … , some insurance
companies will deem the colonoscopy a diagnostic test (rather than a screening test … Ascertaining costs and benefits of colonoscopy more difficult than the procedure itself.
-
psnet.ahrq.gov/node/47175/psn-pdf
July 19, 2018 - paradox of information technology—the fact that
digitization often initially impedes productivity rather … than enhancing it.
-
psnet.ahrq.gov/node/47376/psn-pdf
November 02, 2018 - errors were related to
person-related factors, such as inadequate communication between clinicians, rather … than technological
factors.
-
psnet.ahrq.gov/node/35570/psn-pdf
May 27, 2011 - the national
interest in CPOE, these findings should reinforce the understanding that CPOE is a tool rather … than a
solution for patient safety and that appropriate vigilance in implementation is necessary.