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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
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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.
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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.
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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
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psnet.ahrq.gov/node/47716/psn-pdf
June 26, 2019 - Moreover, the weekend
effect in these studies was more pronounced for elective rather than unplanned
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psnet.ahrq.gov/node/844801/psn-pdf
January 01, 2021 - attributed in large part to frontline
staff's lack of experience in data analysis and reliance on homegrown rather … than externally validated
safety metrics.
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psnet.ahrq.gov/node/42001/psn-pdf
August 02, 2015 - more accurate fourth application, images are sent to a board-certified dermatologist
for evaluation, rather … than using a preset algorithm.
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psnet.ahrq.gov/node/40231/psn-pdf
February 23, 2011 - see link below] discusses the study findings
and emphasizes the continued need to run toward science rather … than away from it in evaluating quality
improvement efforts.
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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
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psnet.ahrq.gov/issue/experience-trigger-tool-identifying-adverse-drug-events-among-older-adults-ambulatory-primary
June 07, 2023 - 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.
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psnet.ahrq.gov/issue/work-patterns-and-fatigue-related-risk-among-junior-doctors
July 29, 2020 - discovered that night work and unpredictable schedules were associated with greater fatigue measures than … which also suggested that error reduction strategies should consider the nature of residents' work rather … than simply the number of hours worked.
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psnet.ahrq.gov/issue/impact-interruptions-duration-nursing-interventions-direct-observation-study-academic
February 13, 2019 - Recognizing this, commentators have called for research to analyze the causes and effects of interruptions, rather … than attempting to categorically prevent interruptions. … Interventions that were interrupted took longer than uninterrupted tasks, and interruptions were a significant … August 14, 2013
Implementing a surgical checklist: more than checking a box.
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psnet.ahrq.gov/issue/primary-care-physicians-willingness-disclose-oncology-errors-involving-multiple-providers
July 28, 2014 - widespread calls for full disclosure of medical errors, physicians often choose their words carefully rather … than explicitly detail how errors may have occurred. … More than three-quarters of physicians in the breast cancer case said they would offer either no information … July 28, 2014
More than words: patients' views on apology and disclosure when things
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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.
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psnet.ahrq.gov/node/49695/psn-pdf
October 01, 2013 - When a phenytoin dose much greater than normal is prescribed, the EMR triggers an alert for the
clinician … Examples of ways to increase specificity include classifying medications as
individual agents (rather … than by classes of medication) and specifying the route of administration. … psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
Rather … Rather than implementing the entire suite of alerts available in an EMR/CPOE initially, a more
sensible
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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
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psnet.ahrq.gov/node/37510/psn-pdf
March 04, 2011 - The authors advocate for use of PSIs in research settings rather than for
purposes of measuring quality
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psnet.ahrq.gov/node/34949/psn-pdf
June 23, 2009 - medical and surgical teams using the intervention,
significantly more time was spent seeing patients rather … than collecting data, improvements were reported
in both sign-out and continuity of care, and nearly
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psnet.ahrq.gov/node/47529/psn-pdf
January 21, 2019 - analysis of the intervention found that most
medication-related harm occurred in the community (70%) rather … than the hospital and that the intervention
successfully reduced community-acquired harm.
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psnet.ahrq.gov/node/43567/psn-pdf
October 21, 2016 - Focusing on specific high-risk drug classes, rather than pursuing the commonly
advocated approach of