-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
December 01, 2017 - First-order problem solving is reactionary, rather than proactive. … Rather than being the main instigators of an accident, operators tend to be the inheritors of SYSTEM … As James Reason wrote more than two decades ago, “Rather than being the main instigators of an accident … Seek to understand rather than to judge. Ask clarifying questions and followup questions. … You need to understand rather than judge. Ask clarifying questions if you’re not sure.
-
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/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/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/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/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/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/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
January 01, 2024 - multisystem illness is diagnosed can be attributed to a maladaptive emotional reaction to the
diagnosis, rather … treatment approaches generally rely on expert clinical experience
attuned to subtle atypical features rather … Psychotic presentations with atypical features lead to greater suspicion of a systemic, rather than … • Lack of personal history of schizoid
personality disorder
• Visual, olfactory, and/or tactile rather … than
auditory hallucinations
• Prominent cognitive impairment
• Concurrent motor signs
• Catatonia
-
www.ahrq.gov/talkingquality/explain/numbers.html
November 01, 2018 - Rather, they are accustomed to getting the information they think they need from people they trust, including … to focus on concerns about the costs of insurance and services, and difficulties in accessing care, rather … than issues of quality and safety.
-
psnet.ahrq.gov/node/49667/psn-pdf
October 01, 2012 - also possible to program machines to make it impossible to
select a patient's medication from more than … Mistakes with medications occur not because a clinician has been incompetent by
making an error, but rather … is important to
acknowledge that medication errors generally occur as a result of system failures rather … than faults
produced by particular people. … Medication errors generally occur as a result of system failures rather than faults produced by
particular
-
www.ahrq.gov/data/apcd/envscan/app-a.html
June 01, 2017 - Some issues that pertain to APCD use occur with any claims database with more than one payer and literature … the type of data and the approach used in the paper (e.g., “all-payer,” “cost,” “episode of care”) rather … than specific clinical terms or titles of quality measures that might be needed for a more focused topical … However, given the brief nature of the current review, the team used this method only for seminal papers, rather … than all research and overview papers.
-
www.ahrq.gov/research/findings/final-reports/ptmgmt/summary.html
July 01, 2018 - Rather than being prescriptive or hierarchical, coaching interventions should be patient-centered and … whether or not patients comply with their medication regimen is a better indicator of a program's success than … possible, rely on information that is directly available from an objective source (e.g., pharmacy records) rather … than a patient's own report.
-
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
-
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/867631/psn-pdf
February 26, 2025 - Patients whose ED note contained the word "homeless" were more likely to be
discharged rather than admitted
-
psnet.ahrq.gov/node/866590/psn-pdf
August 28, 2024 - three-
quarters of proposed risk controls outlined in the plans were weak (focusing on individual rather … than
systemic issues).
-
psnet.ahrq.gov/node/60269/psn-pdf
April 29, 2020 - extend beyond the borders of the
overlying skin changes, requiring much more extensive debridement than … the necessary but less surgically
rewarding operations (like NSTI debridement), and often work alone rather … However, rather than working together to provide a double layer of
security, this dual ‘ownership’ resulted … important, that will ultimately lead to a culture of safety,
where doing the safe thing feels natural, rather … than enforced, thus augmenting rather than diminishing
physician autonomy.13
Take-Home Points
Necrotizing
-
psnet.ahrq.gov/node/34758/psn-pdf
January 29, 2019 - https://psnet.ahrq.gov/issue/normal-accidents-living-high-risk-technologies
Though less often cited than … tight coupling" as the two factors that create an environment in which a major accident becomes more
rather … than less probable over time, regardless of steps taken to increase safety.