-
psnet.ahrq.gov/node/60055/psn-pdf
March 18, 2020 - the app could affect safety, citing that safety was the responsibility of the clinical staff
alone rather … than patients.
-
psnet.ahrq.gov/node/73866/psn-pdf
September 22, 2021 - 19 cases in nursing homes is related to ownership status, facility size and average
occupancy rate, rather … than quality (as measured by infection prevention and control deficiencies).
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psnet.ahrq.gov/node/44476/psn-pdf
September 26, 2016 - Recognizing
this, commentators have called for research to analyze the causes and effects of interruptions, rather … than
attempting to categorically prevent interruptions. … Interventions that were interrupted took longer than
uninterrupted tasks, and interruptions were a significant
-
psnet.ahrq.gov/node/44671/psn-pdf
September 20, 2016 - widespread calls for full disclosure of medical errors, physicians often choose their words carefully
rather … than explicitly detail how errors may have occurred. … More than three-quarters
of physicians in the breast cancer case said they would offer either no information
-
psnet.ahrq.gov/node/46534/psn-pdf
January 31, 2018 - They also felt that
requirements should be tailored to individual surgical experience rather than standardized
-
psnet.ahrq.gov/node/43692/psn-pdf
April 22, 2015 - perioperative deaths were not due to surgical error and advocates
for focusing on failure to rescue rather … than surgeon-specific mortality data in public reporting.
-
psnet.ahrq.gov/node/44557/psn-pdf
November 20, 2015 - This commentary
highlights the importance of using a systems approach to address problems rather than
-
psnet.ahrq.gov/node/44984/psn-pdf
April 13, 2016 - The authors recommend screening for physician fitness based
on overall physical and mental health rather … than at a given age threshold.
-
psnet.ahrq.gov/node/43858/psn-pdf
February 18, 2015 - study suggested that calling a rapid
response is felt to only be justifiable in extreme situations rather … than beforehand, which severely limits the
potential effectiveness of this intervention.
-
psnet.ahrq.gov/node/44062/psn-pdf
September 09, 2015 - operating
environment of error reporting systems—for example, taking steps to improve safety culture—rather … than
the technical specifications of the systems.
-
psnet.ahrq.gov/node/47410/psn-pdf
April 10, 2019 - found that postdischarge home visits from pharmacists focused on the details of the
medication regimen rather … than health beliefs and extent of medication adherence.
-
psnet.ahrq.gov/node/37120/psn-pdf
March 24, 2011 - patient-safety-culture-primary-care-developing-theoretical-framework-practical-
use
Past research on safety culture in the ambulatory setting has focused on assessment rather … than a
framework for action.
-
psnet.ahrq.gov/node/44474/psn-pdf
September 24, 2016 - that
interruptions be considered a process with various potential consequences for multiple actors rather … than
single events and suggests a human factors approach to addressing interruptions.
-
psnet.ahrq.gov/node/43512/psn-pdf
September 29, 2017 - interruptions in health care, this commentary reveals that most studies
focus on the rate of interruptions rather … than the relationship between interruptions and errors.
-
psnet.ahrq.gov/node/33878/psn-pdf
April 01, 2019 - JM: Michelle Mello, Marie Bismark, and I did some research in New Zealand rather than Australia, so it … So, rather than suing the person
who we deem "responsible" for the harm, it's administered by the government … It's more than just letting patients talk. … Apologies are
important, but begin with listening and asking what patients need rather than assuming … Some children are very emotionally intelligent, and it should be based on maturity rather than just the
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-facguide.docx
January 01, 2017 - step toward realizing that medical errors, in large part, do not belong to individual providers, but rather … When we focus on systems rather than individuals, we realize that we can redesign care and delivery processes … Slide 7
Health Care is a Science
SAY:
When we treat medicine and health care delivery as a science rather … than an art, providers can focus on health care delivery processes using evidence-based practices.
-
psnet.ahrq.gov/node/49747/psn-pdf
December 01, 2015 - 170 audible false alarms each day, more than 7 per hour. … Consequently, rather
than signaling that something is wrong, the cacophony becomes "background noise … with
persistent atrial fibrillation (an irregular heart rhythm that can trigger telemetry alarms) rather … than only a select few leads. … https://psnet.ahrq.gov//#references
Take-Home Points
Alarms should never be completely silenced; rather
-
psnet.ahrq.gov/node/49797/psn-pdf
June 01, 2017 - system frequently, have serious medical conditions, and are more likely to be admitted to
the hospital than … use diagnoses, yet typically their chief
complaint in the ED is not related to these conditions, but rather … In such instances, providers may rely on documentation from previous
visits rather than taking extra … than to
a step-down or intensive care unit setting that would allow for more intensive monitoring. … than automatically labeling a patient as a "poor historian."
-
psnet.ahrq.gov/primer/root-cause-analysis
March 30, 2022 - Staffing An ICU nurse, already caring for two other patients, mistakenly administered dialysis liquid rather … than polyethylene glycol solution through a feeding tube. … When she was later weighed, her actual weight was 30kg higher than her guessed weight, which meant her … cardiology department used a homegrown, error-prone scheduling system that identified patients by name rather … those that performed fewer than four.
-
www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-eval-roadmap/ccre-roadmap3.html
July 01, 2013 - field that is relatively underdeveloped, the Roadmap is meant to provide direction for next steps, rather … than a definitive vision of the ultimate research and measurement goals.