-
psnet.ahrq.gov/node/44039/psn-pdf
December 23, 2016 - profoundly changed clinician workflow, resulting in unintended consequences that in some
cases have harmed rather … than helped patients.
-
psnet.ahrq.gov/node/38359/psn-pdf
May 27, 2010 - surgical-safety-checklist-reduce-morbidity-and-mortality-global-population
Success in patient safety is generally measured in incremental steps rather … than giant leaps, but this
pioneering study certainly represents the latter.
-
psnet.ahrq.gov/node/46913/psn-pdf
May 09, 2018 - This implementation study examined factors related to checklist use in the
operating room for crises rather … than routine practice.
-
psnet.ahrq.gov/node/38805/psn-pdf
April 04, 2011 - who apologized and took responsibility for an error and that their perception of this interaction,
rather … than the actual words expressed, was more important.
-
psnet.ahrq.gov/node/43690/psn-pdf
March 26, 2015 - All stakeholders reinforced the need for tailored, interactive, multi-modal communication
rather than
-
psnet.ahrq.gov/node/46297/psn-pdf
March 21, 2018 - The reasons for order cancellation were more accurately reported during provider interviews rather
than
-
psnet.ahrq.gov/node/46012/psn-pdf
December 21, 2017 - The authors conclude that differences in illness severity rather than health care
team staffing explain
-
psnet.ahrq.gov/node/40232/psn-pdf
February 23, 2011 - 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.
-
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
-
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
-
effectivehealthcare.ahrq.gov/sites/default/files/s5.pdf
October 01, 2007 - especially valuable for
evaluating outcomes under conditions of actual use of health
care services (rather … than through RCTs); randomization
occurs by “clusters” that can be defined by physicians, prac-
tices … Control and Prevention,
is another approach for detecting ADEs treated in such
settings (ie, outpatient rather … residual confounding or cen-
soring of data.15 Individual-agent simulations (in which
individuals, rather … One such variable may be physicians’ preferences for
using one type of pharmaceutical rather than another
-
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.
-
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?
-
psnet.ahrq.gov/node/33647/psn-pdf
March 01, 2007 - A nurse administered epinephrine intravenously (rather than the appropriate
route? … Amazingly, less than a year later, she returned to her hospital for emergency treatment. … such as a wife who informed a nurse that
her husband was being placed in his roommate's hospital bed rather … than his own.(2)
https://psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
https://psnet.ahrq.gov
-
digital.ahrq.gov/sites/default/files/docs/publication/r01hs014891-gazelle-final-report-2008.pdf
January 01, 2008 - than the potential to improve quality and safety. … than the potential to improve
quality and safety. … Our analysis was more comprehensive than prior studies. … than at 100% (that is, by 90% of the adjusted slope). … The modeled percentage over
three days dropped by more than half from more than 40% to under 20%.
-
psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - psychologist James Reason, suggests that safety failures are rarely caused by a single human error;
rather … There was not a single cause of this adverse drug event, but rather multiple failures in
the system. … than the provider entering
every order themselves. … , or its brand name, Topamax™, than does trimethobenzamide alone. … The provider
approving topiramate rather than trimethobenzamide is an individual level error, which
-
psnet.ahrq.gov/node/33783/psn-pdf
April 01, 2015 - We knew it wasn't just a
matter of ticking off a checklist, but to see how much has to be done is rather … I said rather flippantly, "You'll get it back." … So many of us are hopeful that as we change the
financing, which seems to be moving ahead rather rapidly … out how to make it more efficient so that doctors find that using electronic
records saves them time rather … than costs them time.
-
psnet.ahrq.gov/perspective/conversation-lucian-leape-md
June 12, 2019 - We knew it wasn't just a matter of ticking off a checklist, but to see how much has to be done is rather … I said rather flippantly, "You'll get it back." … So many of us are hopeful that as we change the financing, which seems to be moving ahead rather rapidly … out how to make it more efficient so that doctors find that using electronic records saves them time rather … than costs them time.
-
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/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?