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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.293_slideshow.ppt
March 01, 2013 - patient's mother called the ED to report that the patient's discharge paperwork listed a weight of 25 kg rather … than her true weight of 25 lbs (11.3 kg). … Other than mild and self-limited diarrhea, there were no significant adverse effects from the four larger … automation complacency
In our case, a clinician hand writing this patient’s weight (25 kg or 55 pounds)—rather … than relying on automation—would have likely realized the computer-listed weight was incongruent with
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psnet.ahrq.gov/node/49462/psn-pdf
October 01, 2004 - causes, the solutions offered by this approach rely on
improving the design of artifacts in the world rather … than relying on labels, instructions, training, or the usual
admonition to "be more careful … Christmas tree adapters to the correct flowmeter; and - Use clear Christmas
tree adapters rather … than color-coded ones. … Look for possible design
solutions wherever possible rather than relying solely on training, warnings
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psnet.ahrq.gov/issue/overestimation-clinical-diagnostic-performance-caused-low-necropsy-rates
February 09, 2011 - diagnoses may represent limitations of current technology or atypical presentations of these conditions rather … than errors. … Nonetheless, clinically significant diagnoses escape detection at a greater rate than is generally appreciated
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psnet.ahrq.gov/issue/who-gets-benefit-doubt-performance-evaluations-medical-errors-and-production-gender
May 01, 2012 - transition roles from student to health care professional and whether differences in resident performance (rather … than differences in perceptions of performance) contribute to gender disparities in evaluations. … comparing feedback on medical errors, women receive more harsh criticism and less supportive feedback than
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psnet.ahrq.gov/issue/shining-light-safer-health-care-through-transparency
November 23, 2016 - Health care has historically treated data as something to be safeguarded rather than openly discussed … July 26, 2023
Broken Trust: Making Patient Safety More than Just a Promise.
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psnet.ahrq.gov/web-mm/finding-fault-default-alert
August 28, 2024 - 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. … Rather than implementing the entire suite of alerts available in an EMR/CPOE initially, a more sensible … Rather than implementing the entire suite of alerts available in an EMR/CPOE initially, a more sensible
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psnet.ahrq.gov/node/43594/psn-pdf
May 01, 2015 - teams have been widely deployed to
address this problem, but this approach is fundamentally reactive rather … than proactive and has had mixed
results so far.
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psnet.ahrq.gov/node/36629/psn-pdf
January 05, 2017 - The vast majority of events related to service quality rather than quality of care.
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psnet.ahrq.gov/node/42433/psn-pdf
October 08, 2013 - The seminal Keystone ICU study used a similar
approach—framing infection control as a social issue rather … than a disease problem—to successfully
reduce catheter-associated bloodstream infections.
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psnet.ahrq.gov/node/36201/psn-pdf
July 10, 2008 - their words carefully" when discussing errors with patients, often opting to discuss "adverse
events" rather … than explicitly admit errors.
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psnet.ahrq.gov/node/38558/psn-pdf
February 18, 2011 - (among the hospital discharge summary, SNF referral form, and SNF admission
orders) were the rule rather … than the exception.
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psnet.ahrq.gov/node/39581/psn-pdf
January 03, 2017 - Proponents of RRS have argued that negative studies reflect
failed implementation of RRS, rather than
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psnet.ahrq.gov/issue/relationship-between-patients-perception-care-and-measures-hospital-quality-and-safety
February 13, 2019 - Although past research suggests that patient complaints relate more to service quality rather than … likelihood to recommend" a hospital had strong associations with technical performance measures in more than … 'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than
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psnet.ahrq.gov/issue/recognizing-excellence-diagnosis-recommended-practices-hospitals
June 21, 2023 - Diagnostic safety is beginning to be established as a systemic , rather than solely an individual performance
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
September 27, 2023 - than to CNS manifestations of SLE itself. … treatment approaches generally rely on expert clinical experience attuned to subtle atypical features rather … than diagnostic protocols based on randomized controlled trials. … presentations with atypical features , shown in Table 1 , lead to greater suspicion of a systemic, rather … Psychotic Presentations with Atypical Features 4 Visual, olfactory, and/or tactile rather than auditory
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psnet.ahrq.gov/node/42759/psn-pdf
April 24, 2017 - programs often inhibit safety culture, because they are perceived as focusing on punitive actions rather … than quality improvement.
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psnet.ahrq.gov/node/35853/psn-pdf
May 20, 2015 - limitations in relying solely on the evidence is a failure to account for
interventions that affect systems rather … than individuals.
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psnet.ahrq.gov/issue/patient-safety-primary-care-conceptual-meanings-health-care-team-and-patients
September 28, 2022 - providing appropriate, timely care) better reflect the experiences of healthcare personnel and patients rather … than domain-based conceptualizations (e.g., diagnosis, care transitions, and medications).
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psnet.ahrq.gov/issue/diagnostic-reliability-teledermatology-systematic-review-and-meta-analysis
September 23, 2020 - significantly higher agreement when dermatologists conducted face-to-face and teledermatology consults, rather … than non-specialists (i.e., primary care or emergency medicine physicians).
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psnet.ahrq.gov/issue/making-healthcare-safer-understanding-designing-and-buying-better-it
February 20, 2019 - can remain unrecognized due to insufficient reporting and the tendency to place blame on the user rather … than question whether the equipment functioned appropriately .