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psnet.ahrq.gov/node/60865/psn-pdf
August 31, 2020 - KH: Let’s go back to a couple of points you have made that I’d like to highlight. … KH: That idea really resonates - bringing together the culture and person and family engagement as
methods
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psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
June 01, 2010 - During high-risk procedures, providers must be allowed to focus on the procedure without interruptions … (iv) ED systems for teamwork and handoffs as well as guidelines for procedures and checklists should … Risks of complications by attending physicians after performing nighttime procedures. … [go to PubMed]
Table
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Table. Model of Patient Safety. … That's in contrast to a slower analytical, deductive method that's much more precise and often yields
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
February 22, 2023 - Recognition of the multifactorial contributors to diagnostic safety spans back almost 20 years with Dr … work on diagnostic error in 2005, which includes an identification of systemic problems with policy, procedures … Recently, researchers and clinicians have debated methods for calculating error rates. … Methods to Improve Diagnostic Safety
Because misdiagnosis arises from complex factors, reducing misdiagnosis
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psnet.ahrq.gov/node/848107/psn-pdf
April 26, 2023 - Recognition of the multifactorial contributors to diagnostic safety spans back almost 20 years with … work on diagnostic error in 2005, which includes an identification of
systemic problems with policy, procedures … Recently, researchers and clinicians have debated methods for calculating error rates. … Methods to Improve Diagnostic Safety
Because misdiagnosis arises from complex factors, reducing misdiagnosis
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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - If that is not part of this organization, we could put that RCA back on the shelf and not look at it … Jessica Behrhorst: When we teach RCA 2 , we stress that it is a toolkit, not just one tool. … I often think back to my early career. … Several years back, RCA 2 got approval from The Joint Commission. … For these reasons, the RCA method is supported by leading accrediting and federal agencies as a way
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - For these reasons, the RCA method is supported by leading accrediting and federal agencies as a way … If that is not part of this organization, we could put that RCA back on the shelf and not look at it … Jessica Behrhorst: When we teach RCA 2 , we stress that it is a toolkit, not just one tool. … I often think back to my early career. … Several years back, RCA 2 got approval from The Joint Commission.
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - Methods Inf Med. 2011;50:447-453. [go to PubMed]
2. Relihan E, O'Brien V, O'Hara S, Silke B. … You can get back into the task. … They teach us a lot about the sorts of systems we can eventually put in place to minimize distraction … that the person using your system might be distracted, turn away to do something else, and then come back … Of course the person answered the text message and went back and forgot to order the medicine and it
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - answer, although the mistake would most likely be attributed to an unexplainable lapse in following procedures … To prevent unintentional unsafe acts—slips, lapses, mistakes, or procedure violations—the contributory … Make it easy to report and provide several different reporting methods. … October 27, 2010
Procedures should promote patient safety.
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - number of handoffs, which has been associated with more medical errors. 10 As a result, a structured method … draw attention to the vegetation finding in this case earlier after patient discharge and transfer back … Another method that may improve effective communication incorporates elements of CLC whereby an alert
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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - port closest to the patient, unless contraindicated or inaccessible for use, such as during a sterile procedure … Vasoplegia after cardiovascular procedures—pathophysiology and targeted therapy. … Errors in the administration of intravenous medications in hospital and the role of correct procedures … Errors and discrepancies in the administration of intravenous infusions: a mixed-methods multihospital … Furniss D, Back J, Blandford A.
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psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
May 01, 2007 - Systematic data collection of the hazards of health care can be traced back at least to the time of Florence … Charles Vincent, PhD Professor of Clinical Safety Research, Imperial College London
References
Back … 1950s and 1960s, it had all been about technical factors: the design of aircraft, the development of procedures … structure, and what seems to be invariable across national boundaries, organizational systems, and payment methods … That's where we can go back to the lessons of the airline industry.
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psnet.ahrq.gov/periodic-issue/periodic-issue-404
August 30, 2023 - interprofessional education (IPE) does or does not improve students' attitudes towards patient safety, the methods … deprived near the end of a 48-hour call shift (during which they only slept for 3 hours), performed the procedure … weight loss, constipation for several days, subjective fevers at home, and mild pain in the chest, back
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psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
August 01, 2007 - targets are not met, they expect corrective action and carefully follow progress until the situation is back … learned that, rather than just fixing things for our practice or the guy down the hall, with the right methods … wonderful stuff we just did," they'd hear"A patient lost their hand in a farm accident and we put it back … If I, as CEO, can look them in the eye and say, the board is expecting us to come back in 3 months with … delays because you have to send it out to get all the data from whoever has to vet the stuff and get it back
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psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
August 01, 2007 - learned that, rather than just fixing things for our practice or the guy down the hall, with the right methods … wonderful stuff we just did," they'd hear"A patient lost their hand in a farm accident and we put it back … If I, as CEO, can look them in the eye and say, the board is expecting us to come back in 3 months with … delays because you have to send it out to get all the data from whoever has to vet the stuff and get it back … targets are not met, they expect corrective action and carefully follow progress until the situation is back
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psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
May 01, 2007 - 1950s and 1960s, it had all been about technical factors: the design of aircraft, the development of procedures … structure, and what seems to be invariable across national boundaries, organizational systems, and payment methods … That's where we can go back to the lessons of the airline industry. … Systematic data collection of the hazards of health care can be traced back at least to the time of Florence … Charles Vincent, PhD Professor of Clinical Safety Research, Imperial College London
References
Back
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psnet.ahrq.gov/node/49651/psn-pdf
May 01, 2012 - Emerging Handoff Curricula
Although numerous curricula and instructional methods have been developed … references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
A common way to teach … to evaluate receivers on use
of active listening behaviors, such as interactive questioning, read-back
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psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - number of handoffs, which has been associated with more medical errors.10 As a
result, a structured method … draw attention to the vegetation finding in this case earlier after patient discharge and
transfer back … Another method that may improve effective communication incorporates elements of CLC whereby an alert
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psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workforce-challenges
August 30, 2023 - The virtual nurse could come back and say, “Hey, did you notice the hemoglobin was this,” or “I’ve had … they were able to find issues and to catch potential problems, such as labs, medication errors, or procedures … Instead of saying to the nurse, “I’m going to teach you how to do it,” she said to the patient, “I’m … Back when we started this, it was such a foreign concept. … It’s an internal technology, consisting of a monitor on the wall, camera, and method of calling.
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psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schuelke-about-virtual-nursing
August 30, 2023 - The virtual nurse could come back and say, “Hey, did you notice the hemoglobin was this,” or “I’ve had … they were able to find issues and to catch potential problems, such as labs, medication errors, or procedures … Instead of saying to the nurse, “I’m going to teach you how to do it,” she said to the patient, “I’m … Back when we started this, it was such a foreign concept. … It’s an internal technology, consisting of a monitor on the wall, camera, and method of calling.
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psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
September 01, 2011 - The VA has done a very good job with getting back to the reporter. … about what makes a good incident reporting system, it sounds like obviously a very strong follow-up procedure … For measuring the actual incidence of safety events, other detection methods are more sensitive, including … errors, are currently addressed through morbidity and mortality conferences and hospital credentialing procedures … The actions that hospital leaders take in response to reports teach providers whether the time and risks