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psnet.ahrq.gov/issue/developing-open-disclosure-strategies-medical-error-using-simulation-final-year-medical
September 29, 2018 - February 22, 2023
Handshake antimicrobial stewardship as a model to recognize and prevent
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psnet.ahrq.gov/issue/accuracy-trigger-tools-detect-preventable-adverse-events-primary-care-systematic-review
January 22, 2016 - January 20, 2016
Incoming interns recognize inadequate physical examination as a cause
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psnet.ahrq.gov/issue/failure-rescue-female-patients-undergoing-high-risk-surgery
October 25, 2017 - Hospital nurses and physicians' experiences practicing patient safety work to recognize
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psnet.ahrq.gov/issue/ergonomic-and-human-factors-affecting-anesthetic-vigilance-and-monitoring-performance
May 31, 2011 - July 14, 2010
Handshake antimicrobial stewardship as a model to recognize and prevent
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psnet.ahrq.gov/issue/value-improving-patient-safety-health-economic-considerations-rapid-response-systems-rapid
January 07, 2015 - 2025
Hospital nurses and physicians' experiences practicing patient safety work to recognize
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psnet.ahrq.gov/issue/antecedent-treat-and-release-diagnoses-prior-sepsis-hospitalization-among-adult-emergency
May 12, 2021 - June 19, 2018
Handshake antimicrobial stewardship as a model to recognize and prevent
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psnet.ahrq.gov/node/49692/psn-pdf
September 01, 2013 - The adverse event was not due to a resident's failure to recognize
certain pathology or the risk that … references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
opportunity to recognize
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psnet.ahrq.gov/node/863002/psn-pdf
February 21, 2024 - Three quarters of preventable patient harm stems from
situation awareness breakdowns: recognizing and
addressing the core issue.
February 21, 2024
Tscholl DW, Hunn CA, Gasciauskaite G. APSF Newsletter. 2024;39:29–30.
https://psnet.ahrq.gov/issue/three-quarters-preventable-patient-harm-stems-situation-awareness-
b…
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psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
January 01, 2020 - • Recognize the importance of documentation all medications
• Acknowledge the importance of handoffs … the intravenous route of administration for the
indication of anxiety
• Because of the failure to recognize
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psnet.ahrq.gov/issue/recognizing-ordinary-extraordinary-insight-way-we-work-improve-patient-safety-outcomes
December 12, 2012 - Commentary
Recognizing the ordinary as extraordinary: insight into the "way we work" to improve patient safety outcomes.
Citation Text:
Henneman EA. Recognizing the Ordinary as Extraordinary: Insight Into the "Way We Work" to Improve Patient Safety Outcomes. Am J Crit Care. 2017;26(4):27…
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psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-trade-offs
November 04, 2020 - Commentary
Scandal as a sentinel event—recognizing hidden cost–quality trade-offs.
Citation Text:
Bloche G. Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. N Engl J Med. 2016;374(11):1001-3. doi:10.1056/NEJMp1502629.
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Format:
DOI Google…
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psnet.ahrq.gov/issue/missing-near-miss-recognizing-valuable-learning-opportunities-radiation-oncology
November 18, 2020 - Study
Missing the near miss: recognizing valuable learning opportunities in radiation oncology.
Citation Text:
Kundu P, Jung OS, Valle LF, et al. Missing the near miss: recognizing valuable learning opportunities in radiation oncology. Pract Radiat Oncol. 2021;11(3):e256-e262. doi:10.101…
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psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
July 10, 2024 - Clearly, all of us who work on the front lines as physicians, nurses, and hospital employees recognize … We use the term "indicators" because we recognize that these are not measures where we can say that every … the action is—the subset of sicker patients—and you pose the hypothesis that better hospitals should recognize
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psnet.ahrq.gov/node/50837/psn-pdf
January 29, 2020 - Better care for surgical patients: recognizing and
responding to the unexpected to save lives.
January 29, 2020
Ghaferi A. IHPI Brief. December 2019.
https://psnet.ahrq.gov/issue/better-care-surgical-patients-recognizing-and-responding-unexpected-save-
lives
Surgical compl…
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psnet.ahrq.gov/node/73149/psn-pdf
April 14, 2021 - Recognizing the importance of whistleblowers in
healthcare.
April 14, 2021
O'Neill N. Recognizing the importance of whistleblowers in healthcare. Nursing (Brux). 2021;51(4):54-56.
doi:10.1097/01.nurse.0000736912.14380.65.
https://psnet.ahrq.gov/issue/recognizing-importance-whistleblowers-healthcare
Individuals wh…
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psnet.ahrq.gov/node/40758/psn-pdf
September 07, 2011 - A review of educational strategies to improve nurses'
roles in recognizing and responding to deteriorating
patients.
September 7, 2011
Liaw SY, Scherpbier A, Klainin-Yobas P, et al. A review of educational strategies to improve nurses' roles
in recognizing and responding to deteriorating patients. Int Nurs Rev. 20…
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - spinal
epidural abscess
• Evaluate for spinal epidural abscess with laboratory testing and
imaging
• Recognize … differential diagnosis at each subsequent visit
despite worsening signs and symptoms
– Failure to recognize … exemplify
anchoring bias when clinicians become “anchored” to an incorrect
diagnosis
– Failure to recognize … incorrect diagnosis of meningitis.
– Each of this patient’s visits represented a missed opportunity to recognize
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psnet.ahrq.gov/node/46388/psn-pdf
September 24, 2017 - Recognizing and responding to the "toxic" work
environment: worker safety, patient safety, and
abuse/neglect in nursing homes.
September 24, 2017
Pickering CEZ, Nurenberg K, Schiamberg L. Recognizing and Responding to the "Toxic" Work
Environment: Worker Safety, Patient Safety, and Abuse/Neglect in Nursing Homes. …
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psnet.ahrq.gov/node/33692/psn-pdf
February 01, 2010 - But we need to recognize that residents are not the
only people handing these patients off. … However, we also have a
responsibility to educate physicians to be able to recognize their limits. … literature indicating that we have some ways to go in setting up systems to
educate physicians to recognize … their fatigue and also to recognize, by the duration of their time on task,
that they may not be optimally
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psnet.ahrq.gov/node/837660/psn-pdf
July 08, 2022 - Recognize persistent neuromuscular blockade prior to extubation
In retrospect, the persistent weakness … relayed to either the pulmonologist or the anesthesiologist because the junior staff member did not
recognize … If the patient does not recognize the significance of the event, it is unlikely
that the problem will