-
psnet.ahrq.gov/node/36812/psn-pdf
June 30, 2011 - 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/node/35467/psn-pdf
March 11, 2011 - nurses but increased it for physicians,
particularly when using centrally located desktop workstations rather … than bedside point-of-care systems. … While some systems undoubtedly perform better than others in this regard, efforts to
implement EHRs
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psnet.ahrq.gov/node/33826/psn-pdf
February 01, 2017 - than be replaced) and see what that might look like. … We will need to have two-way conversations—rather than one way (boss-to subordinate)." … RW: Right, I assume you saw that as a lesion and a flaw rather than the nature of the business. … than individual performance. … than serve
the patient.
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psnet.ahrq.gov/node/37825/psn-pdf
April 11, 2011 - inherently responsible for serious patient injury and found that
outdated design and incorrect assembly, rather … than bedrails themselves, contributed to such injuries.
-
psnet.ahrq.gov/node/37564/psn-pdf
June 12, 2008 - medical-emergency-team-system-two-hospital-comparison
This study found that elderly males, patients with greater comorbid conditions, and surgical rather … than
medical patients stimulated medical emergency team activity, suggesting opportunities to further
-
psnet.ahrq.gov/node/35888/psn-pdf
July 23, 2010 - errors associated with continuous renal replacement therapy and found that use of
industry-prepared, rather … than manually compounded, solutions minimized errors.
-
psnet.ahrq.gov/node/37379/psn-pdf
March 28, 2012 - identifying-modifiable-barriers-medication-error-reporting-nursing-home-setting
This study suggests that organizational rather … than individual-level interventions are the key to improving
medication error reporting in nursing
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psnet.ahrq.gov/node/47907/psn-pdf
July 19, 2019 - safety-i-safety-ii-and-burnout-how-complexity-science-can-help-clinician-
wellness
Building on success rather … than reacting to failure is an emerging focus of improvement efforts.
-
psnet.ahrq.gov/node/72482/psn-pdf
November 18, 2020 - 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.
-
psnet.ahrq.gov/node/73074/psn-pdf
March 24, 2021 - The authors discuss failures
including the lack of data auditing and a focus on ratings rather than
-
psnet.ahrq.gov/node/47982/psn-pdf
July 31, 2019 - measure speaking-up behaviors of medical students and the
general public, using a masked experiment rather … than asking participants to report their behaviors or
comfort level.
-
psnet.ahrq.gov/node/836859/psn-pdf
April 06, 2022 - clinicians that uncertainty is a part
of medicine and shifting to a focus on patient-centered management rather … than focusing on identifying a
diagnosis.
-
psnet.ahrq.gov/issue/who-world-alliance-patient-safety-new-challenge-or-old-one-neglected
February 14, 2024 - systemic issues and highlight the importance of both these approaches being used in a collaborative, rather … than independent, fashion. … August 26, 2020
Adverse events in infants less than 6 months of age after ambulatory
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psnet.ahrq.gov/node/866158/psn-pdf
June 19, 2024 - increasing proportion of surgeries are performed in freestanding ambulatory surgery centers (ASCs)
rather … than in hospitals.
-
psnet.ahrq.gov/issue/enhancing-safe-medication-use-home-care-insights-informal-caregivers
December 02, 2020 - tasked with increasingly complex care regimens as many care recipients prefer to stay in their homes rather … than move to a residential facility. … On average, 13.5 medication errors per caregiver per year were self-reported, with more than half of … Caregivers who cared for multiple recipients reported more errors than caregivers who reported sharing
-
psnet.ahrq.gov/node/60169/psn-pdf
March 25, 2020 - in the mind of these
anesthesia care providers that this fluid is intended for bladder irrigation rather … than for intravenous
therapy. … The ototoxicity in the cases presented may be vestibular rather than
cochlear in nature and therefore … may produce permanent loss of balance rather than hearing loss.7 Given
these significant side effects … The risk of fluid overload in this
case was less important than the risk of gentamicin nephrotoxicity
-
psnet.ahrq.gov/issue/gaps-specialists-diagnoses
July 28, 2021 - that specialists are more vulnerable to anchoring bias and more siloed approaches to problem solving than … hone their generalist skills, seek multidisciplinary consultation , and focus on patient-centered rather … than disease-centered care to ensure a wide range of considerations are explored to avoid diagnostic
-
psnet.ahrq.gov/issue/clinical-problem-solving-lost-transcription
September 20, 2011 - involves an iatrogenic reaction that occurred due to mistakenly administering methotrexate daily, rather … than weekly. … Bronchoscopy, Two Errors
January 1, 2019
Promethazine conundrum: IV can hurt more than
-
psnet.ahrq.gov/node/37242/psn-pdf
September 12, 2016 - The authors conclude that the original definition, which uses all
deaths rather than specific complications
-
psnet.ahrq.gov/node/37216/psn-pdf
July 28, 2010 - administrative measures, including length of stay
and patient volume, by using a nurse practitioner (rather … than a physician trainee) to participate in
multidisciplinary rounds.