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psnet.ahrq.gov/issue/real-time-debriefing-after-critical-events-exploring-gap-between-principle-and-reality
December 15, 2021 - This review examines how debriefing principles can be embedded for use of the practice in real time, rather … than developed in simulated circumstances, to improve anesthesia safety.
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psnet.ahrq.gov/issue/evolution-procedural-competency-internal-medicine-training
December 15, 2021 - The authors suggest that focusing on procedural experience rather than technical skill can help clinicians
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psnet.ahrq.gov/issue/error-disclosure-and-family-members-reactions-does-type-error-really-matter
March 08, 2023 - , apologize, and display empathy when the scenario represented an instance of clear responsibility rather … than shared responsibility or system failure .
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psnet.ahrq.gov/issue/are-second-victims-getting-help-they-need
September 13, 2017 - second victim support programs, such as an established culture of safety, focus on emotional needs rather … than skill assessment, and sustained leadership engagement in the program.
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psnet.ahrq.gov/node/72737/psn-pdf
February 09, 2021 - prior to implementation, the treatment culture in PA focused on an
inpatient abstinence-only model rather … required to attend fewer clinic visits and counseling verification
requirements are less stringent than … The all-cause mortality rate among individuals in the program is 81%
lower than in individuals with … implementation of this intervention, substance
use disorder has frequently been treated as a choice rather … than a disease.
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psnet.ahrq.gov/primer/patient-engagement-and-safety
August 30, 2023 - Concerns have been raised, however, that patient complaints may center on poor service quality rather … than on clinical adverse events. … in safety efforts has extended to allowing patients and families to summon rapid response teams , rather … than waiting for clinicians to respond.
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psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
October 01, 2016 - to become prevention rather than response—is important. … it needs to be, rather than because a small fraction of hospitals or practices have outlier rates. … came back from Liberia, and somehow if those databases got merged with a patient presenting with fever rather … than these dual assessments, could we get better at this? … Rather than reflecting the clinician's intention, the data faithfully encodes the ostensibly capricious
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psnet.ahrq.gov/node/49586/psn-pdf
May 01, 2009 - When the ACT returned normal rather than prolonged
(as it should have been after the heparin), the anesthesiologist … He quickly realized that the
heparin vial from the garbage was a 10 units/mL concentration rather than … and three were injured when nurses
administered heparin flushes prepared from 10,000 units/mL vials rather … than from similar-looking vials
containing the 10 units/mL concentration used to flush intravenous … heparin selections had a four-fold higher
incidence of averted programming errors identified by the DERS than
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psnet.ahrq.gov/node/49637/psn-pdf
October 01, 2011 - As a result, the
truncated report read, "DVT is seen…" rather than "No DVT is seen…" Based on the verbal … discrepancy between the called report and the finalized report, they should
have had the images re-reviewed rather … than accepting reassurance from the on-call resident that the
dictating radiologist had the necessary … VRS tend to have fewer errors when the entire report is dictated as a whole rather than being dictated … it seems that the
likelihood of him/her choosing the first when they meant the latter would be less than
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psnet.ahrq.gov/node/43571/psn-pdf
October 01, 2014 - successful implementation, highlighting that failure to follow up on
concerns raised may actually erode, rather … than enhance, safety culture.
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psnet.ahrq.gov/node/34053/psn-pdf
March 02, 2011 - recommendations to
reduce the incidence of VAP, including use of semi-recumbent positioning, sucralfate rather … than H2-
antagonists, and aspiration of subglottic secretions in select patient populations.
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psnet.ahrq.gov/node/44056/psn-pdf
May 19, 2018 - As payment models
increasingly shift toward paying for value rather than volume, the negative financial
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
November 01, 2008 - production and quality of work-life pressures
A: Communication is not a macrocognitive function, but rather … Narratives (“stories”) are primary vehicle for compactly constructing meaning in a shared conversation, rather … than a one-way transfer of independent data elements via a noisy communication channel
L: Handoff procedures … ” approach following a undesired outcome, as it may serve as a barrier to making health care safer
Rather … than making changes on a single case, explore applying desired trade-off weightings across a range of
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psnet.ahrq.gov/web-mm/dropped-no
October 30, 2019 - As a result, the truncated report read, "DVT is seen…" rather than "No DVT is seen…" Based on the verbal … discrepancy between the called report and the finalized report, they should have had the images re-reviewed rather … than accepting reassurance from the on-call resident that the dictating radiologist had the necessary … VRS tend to have fewer errors when the entire report is dictated as a whole rather than being dictated … it seems that the likelihood of him/her choosing the first when they meant the latter would be less than
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psnet.ahrq.gov/node/33571/psn-pdf
March 15, 2025 - (e.g., the nurse, pharmacist, or physician caring for a patient when a medication
error occurred), rather … than management or patient safety professionals. … emphasizes analysis of the events and documenting
process improvements arising from event analysis, rather … than encouraging event reporting for its own
sake.
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psnet.ahrq.gov/node/50610/psn-pdf
October 30, 2019 - Maci
experienced more than 1200 separate interventions, many of them painful, that conferred risk to … no longer be necessary given progress in noninvasive methods of monitoring,
and may cause more harm than … intravenous to
oral medications (or stopping medications) as soon as possible, and use of placental blood rather … than
infants' blood on admission.(5)
This approach uses a daily count of interventions (POKEs) to … neonatologist synthesizes the
recommendations into the care plan.(7)
This care model is not a distant utopia, rather
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psnet.ahrq.gov/node/33728/psn-pdf
May 01, 2012 - Hospital and we could identify triggers
in real time, we decided to cast the net a little bit wider rather … than a little bit narrower. … , it's not just preventability—it's the ability
to actually intervene in real time and to mitigate rather … than just prevent—so it changes the equation. … than just preventability?
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psnet.ahrq.gov/node/33712/psn-pdf
June 01, 2011 - It's an organizational problem more than a technological one. … The epiphany was to approach these issues as system problems rather than manifestations of individual … than to wait
until a larger number of events have occurred. … take a certain kind of
consistent courage in all parts of organizations to face potential problems rather … than to make a series of
optimistic assumptions.
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psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
February 24, 2021 - As with most clichés and stereotypes, probably more surgeons behave this way than other physicians; however … Once pericardiocentesis was finally performed, the child immediately improved and more than 200 cc of … Rather, we need to ask: Under what conditions are social arrangements once thought unassailable and uncontested … For Weick, “safety cultures” seek wisdom rather than knowledge alone, couple confidence in skill with … A number of factors are critical if safety cultures are to become a reality rather than a rhetorical
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psnet.ahrq.gov/issue/work-life-balance-behaviours-cluster-work-settings-and-relate-burnout-and-safety-culture
September 14, 2022 - 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