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psnet.ahrq.gov/node/42981/psn-pdf
March 19, 2014 - Recognizing and managing errors of cognitive
underspecification.
March 19, 2014
Duthie EA. Recognizing and managing errors of cognitive underspecification. J Patient Saf. 2014;10(1):1-5.
doi:10.1097/PTS.0b013e3182a5f6e1.
https://psnet.ahrq.gov/issue/recognizing-and-managing-errors-cognitive-underspecification
Inc…
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psnet.ahrq.gov/node/46508/psn-pdf
November 22, 2017 - The checklist: recognize limits, but harness its power.
November 22, 2017
Alspach JAG. The Checklist: Recognize Limits, but Harness Its Power. Crit Care Nurse. 2017;37(5):12-18.
doi:10.4037/ccn2017603.
https://psnet.ahrq.gov/issue/checklist-recognize-limits-harness-its-power
Checklists are used in various health c…
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psnet.ahrq.gov/node/73617/psn-pdf
August 26, 2021 - Recognizing Unsafe Care: What It Is and How to Report It.
August 18, 2021
Patient Safety Foundation. August 26, 2021.
https://psnet.ahrq.gov/issue/recognizing-unsafe-care-what-it-and-how-report-it
This webinar introduced medical error and harm as related concepts to identify unsafe care and enhance
response, engag…
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psnet.ahrq.gov/node/33810/psn-pdf
June 01, 2016 - I chose to pursue the well-
recognized Certified Professional in Patient Safety (CPPS) certificate,
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psnet.ahrq.gov/node/837813/psn-pdf
January 21, 2021 - Recognizing Excellence in Diagnosis.
January 21, 2021
The Leapfrog Group.
https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis
Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise
to be successful. This collaborative initiative will initially dev…
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psnet.ahrq.gov/web-mm/lap-burn
March 01, 2018 - patient suffered only a minor burn and had no long-term sequelae; fortunately, the burning drapes were recognized … The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has recognized the risk of
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psnet.ahrq.gov/node/45021/psn-pdf
April 06, 2016 - Scandal as a sentinel event—recognizing hidden
cost–quality trade-offs.
April 6, 2016
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.
https://psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-t…
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psnet.ahrq.gov/issue/recognizing-our-biases-understanding-evidence-and-responding-equitably-application
April 05, 2023 - Commentary
Recognizing our biases, understanding the evidence, and responding equitably: application of the socioecological model to reduce racial disparities in the NICU.
Citation Text:
McCarty DB. Recognizing our biases, understanding the evidence, and responding equitably: application…
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psnet.ahrq.gov/issue/better-care-surgical-patients-recognizing-and-responding-unexpected-save-lives
January 11, 2017 - Image/Poster
Better care for surgical patients: recognizing and responding to the unexpected to save lives.
Citation Text:
Better care for surgical patients: recognizing and responding to the unexpected to save lives. Ghaferi A. IHPI Brief. December 2019. &n…
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psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - which-line-ordering-provider-or-proceduralist
When the patient presented for apheresis treatment, providers recognized … In medicine, such a system would have recognized the inappropriate order and
prevented it from being … future, it is possible that the CDS would have
identified the error (perhaps because it would have recognized
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.461_slideshow.ppt
November 01, 2018 - the distress he felt when the medical student was assigned to replace him at the patient's bedside—he recognized … contribute to patient care
Supervisors must decide when they can trust trainees with clinical activities
Recognized
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psnet.ahrq.gov/node/49438/psn-pdf
March 05, 2004 - She was recognized by
someone who passed the OR suite when the door was open. … The patient may be recognized in the same-day surgery admission center, while being
transported on a
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psnet.ahrq.gov/issue/society-critical-care-medicine-guidelines-recognizing-and-responding-clinical-deterioration
April 24, 2018 - Organizational Policy/Guidelines
Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023.
Citation Text:
Honarmand K, Wax RS, Penoyer D, et al. Society of Critical Care Medicine Guidelines on Recognizing and Responding to…
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psnet.ahrq.gov/web-mm/picture-speaks-1000-words
July 16, 2015 - Tragically, the limitation of the workaround was only recognized when a single patient presented with … Take-Home Points Workarounds should be recognized as limited, and perhaps dangerous, processes people
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psnet.ahrq.gov/issue/opinions-nurses-and-physicians-patient-family-and-visitor-activated-rapid-response-system-use
February 14, 2024 - Study
Opinions of nurses and physicians on a patient, family and visitor activated rapid response system in use across two hospital settings.
Citation Text:
King L, Minyaev S, Grantham H, et al. Opinions of nurses and physicians on a patient, family and visitor activated rapid response s…
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psnet.ahrq.gov/issue/excusable-neglect-malpractice-suits-against-radiologists-proposed-jury-instruction-recognize
April 11, 2011 - Commentary
Excusable neglect in malpractice suits against radiologists: a proposed jury instruction to recognize the human condition.
Citation Text:
Excusable neglect in malpractice suits against radiologists: a proposed jury instruction to recognize the human condition. Caldwell C; …
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psnet.ahrq.gov/node/851455/psn-pdf
July 19, 2023 - Student mistakes and teacher reactions in bedside
teaching.
July 19, 2023
Rubisch HPK, Blaschke A-L, Berberat PO, et al. Student mistakes and teacher reactions in bedside
teaching. Adv Health Sci Educ Theory Pract. 2023;28(5):1523-1556. doi:10.1007/s10459-023-10233-y.
https://psnet.ahrq.gov/issue/student-mistakes-…
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psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
January 01, 2022 - RECOGNIZING INJURY
28
Recognizing Injury (1)
29
• Injury from the Veress needle technique may be recognized
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psnet.ahrq.gov/node/853244/psn-pdf
September 06, 2023 - Error traps in pediatric patient blood management in the
perioperative period.
September 6, 2023
Tan GM, Murto K, Downey LA, et al. Error traps in pediatric patient blood management in the perioperative
period. Paediatr Anaesth. 2023;33(8):609-619. doi:10.1111/pan.14683.
https://psnet.ahrq.gov/issue/error-traps-pe…
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psnet.ahrq.gov/issue/three-quarters-preventable-patient-harm-stems-situation-awareness-breakdowns-recognizing-and
September 11, 2009 - Newspaper/Magazine Article
Three quarters of preventable patient harm stems from situation awareness breakdowns: recognizing and addressing the core issue.
Citation Text:
Three quarters of preventable patient harm stems from situation awareness breakdowns: recognizing and addressing the …