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psnet.ahrq.gov/node/866261/psn-pdf
July 10, 2024 - than on
the inside to prevent this potential complication. … Positioning
the hands on an arm board rather than tucking them close to the body eliminates this risk … Patients with a body mass index (BMI) of less than 20 or greater than 30, patients
with diabetes, and … transducer of the arterial line to the level of the ear to measure and record blood
pressure at the brain rather … than at the heart level.
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psnet.ahrq.gov/issue/few-adverse-events-hospitals-were-reported-state-adverse-event-reporting-systems
January 20, 2010 - 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.
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psnet.ahrq.gov/node/838222/psn-pdf
September 28, 2022 - measures, primary care practices sometimes look like they have lower quality
metrics; they’re 70% or 80% rather … than 90%. … So rather than trying to measure 100 things, we wonder how
to determine a parsimonious group of measures … If I see patients five times a year, rather than three times a year, then I can’t see as many
patients … It essentially is designed to support the transactional aspects rather than the
relational aspects.
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psnet.ahrq.gov/node/43859/psn-pdf
May 28, 2015 - prevalence study evaluated checklist use in 426 hospitals across 28
European nations, involving more than … However, it is unclear from this study whether this improvement is due to the
checklist or rather checklist
-
psnet.ahrq.gov/node/33845/psn-pdf
November 01, 2017 - we can study people
and their needs and come up with solutions that blend the best of both worlds, rather … than creating
technology that makes the problem worse. … patients need and how can we
understand their needs and perspectives and develop tools to support them, rather … WP: I see that as an opportunity more than a threat. … RW: You said progress has gone more slowly than you expected.
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psnet.ahrq.gov/node/33649/psn-pdf
May 01, 2007 - Rather, they concerned incompetent or poorly performing doctors, whose colleagues were
covering up for … practitioners, it just means that (a) they're very busy, or (b) they see themselves as a cog in a
machine rather … you expected and what has been harder than you expected? … In the UK, when you're trying to introduce
change, you rather feel that you're in a goldfish bowl. … RW: What's been harder than you thought?
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psnet.ahrq.gov/node/49790/psn-pdf
April 01, 2017 - this particular case, an urticarial reaction to contrast medium
should have been seen as allergic rather … than intolerant in mechanism. … context), that patient may be
inappropriately given alternate and perhaps less effective prophylaxis rather … than a penicillin challenge
being considered.
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - More than half of all
medication errors occur at the interfaces of care.(1) A review of 22 studies by … Rather than hoping that a medication was appropriately discontinued and not overlooked,
this intervention … reconciliation should not be viewed as necessary to meet the
regulatory or accreditation requirements but, rather … hospitals have successfully implemented reconciliation using low-technology solutions (eg,
forms) rather … than computers.
-
psnet.ahrq.gov/node/33832/psn-pdf
April 01, 2017 - Rather than going to a school of public health, I chose to go to a
business school, in part because … We started discussing how this idea of high reliability was probably more
generalizable than had been … literature even in non–health care was fairly sparse and
more around crisis management, Tylenol, etc. rather … In fact, knowing that we've been on this good run
sometimes contributes to less vigilance rather than
-
psnet.ahrq.gov/node/49393/psn-pdf
April 01, 2003 - to the OR for laparotomy, it became apparent that
the diversion had involved the transverse colon rather … than the descending colon. … A second confirmatory test consists of instilling air or
water (rather than a colonoscope) into the … On average, patients have an
ileus that is much shorter with the laparoscopic procedure than with open … It is important to note
that mechanical obstruction can occur for reasons other than the error described
-
psnet.ahrq.gov/node/49656/psn-pdf
June 01, 2012 - hospitalist) increased authority, responsibility, and accountability for the
care of surgical patients.(1) Rather … than simply offering advice to the referring surgeon on a specific
question, comanaging physicians … The chances that a surgical patient
would be comanaged grew by more than 11% per year between 2001 and … more common in
non-teaching hospitals, where surgical patients are often admitted to the hospitalist rather … than the
surgeon.
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
May 01, 2013 - *
*
Case: Right Regimen, Wrong Cancer (3)
Rather than the 3-day regimen for metastatic penile … Such errors likely comprise only 1.4% to 4% of all medication errors
Error rates generally lower than … system to
guarantee safe
handoff
Chemotherapy administration
on a general internal medicine
service rather … than a subspecialty service
?
-
psnet.ahrq.gov/web-mm/more-treatment-better-care
August 11, 2021 - risks of plasmapheresis with the physician and asked him to follow the recommended treatment course rather … harms.( 1 ) We have published 148 articles and commentaries in the series since its inception less than … This means that a focus on the harms rather than the costs of unnecessary, non–evidence-based care may … Similarly, performance measures that focus more on outcomes and overuse than on processes and underuse … 2 weeks ( 17 ) Use outside of selected high-risk group or for too long than known benefit Used in
-
psnet.ahrq.gov/node/33674/psn-pdf
February 01, 2009 - patients' charts that have documentation of
smoking cessation counseling, I would be shocked if more than … My guess
is that the answer is and, rather than or—that as they look at their payment policy and they … Rather,
the successes have come from systematizing practice. … Rather than trying to ask them to remember everything, ask them what does the
system look like that … schools, individual doctors, individual nurses, pharmacists, or hospitals to focus on safety, other than
-
psnet.ahrq.gov/node/50389/psn-pdf
September 25, 2019 - Moreover, these orders
were not placed until more than 3 hours after the patient had presented. … For example,
rather than asking, "Am I falling victim to premature closure in this case?" … and "What if there is more than one thing going on?" … members deferred to the primary oncologist—and thus overemphasized the oncologic emergency at
hand—rather … than considering other diagnoses such as sepsis.
-
psnet.ahrq.gov/node/33882/psn-pdf
June 01, 2019 - learning proactively about how things usually go well and developing ways of supporting the same.(2)
Rather … than reduce variability and mitigate error, resilience engineering strives to enhance the system's … engineering research has focused on identifying how resilience manifests in different work systems rather … than on building a comprehensive readily usable toolkit for application.
-
psnet.ahrq.gov/primer/reporting-patient-safety-events
March 30, 2022 - (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.
-
psnet.ahrq.gov/web-mm/reconciling-doses
August 14, 2017 - More than half of all medication errors occur at the interfaces of care.( 1 ) A review of 22 studies … Rather than hoping that a medication was appropriately discontinued and not overlooked, this intervention … reconciliation should not be viewed as necessary to meet the regulatory or accreditation requirements but, rather … Many hospitals have successfully implemented reconciliation using low-technology solutions (eg, forms) rather … than computers.
-
psnet.ahrq.gov/node/49475/psn-pdf
March 01, 2005 - Instead, the failure occurred
because the IT design was technology-centered rather than human-centered … man–machine interface to be attributed
to human error (eg, "the surgeon should look more carefully") rather … than to poor design.(14) Creating high
quality, human-centered technology is difficult and requires … Cases like this one demonstrate that IT in
health care requires more than simply adding "computerization … Creating robust IT depends on designing health care computer systems to be user-centered rather
than
-
psnet.ahrq.gov/node/49497/psn-pdf
December 01, 2005 - delivery room involve deficiencies in behavioral skills (eg, communication, leadership, and teamwork)
rather … than cognitive (content knowledge) or technical skills (manual dexterity and proficiency). … Rather,
simulation-based training, first in a controlled medical simulator followed by drills in the … The key to simulation-based training lies in the methodology rather than the technology used for
implementation … Much attention has been paid to the sophisticated (and expensive—some more than
$100,000) human patient