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Showing results for "technique".

41. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
    January 01, 2023 - • The surgeon placed the PEG tube in the ICU using the “pull technique” (i.e., via the mouth) because … – Interventional radiologists use a “push technique” to position tubes percutaneously, using only … A “safe track” technique with endoscopic visualization of a fine 25-gauge “finder” needle puncturing … Gastrostomy without laparotomy: a percutaneous endoscopic technique. … Percutaneous endoscopic gastrostomy: indications, technique, complications and management.

42. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43960/psn-pdf
    April 01, 2015 - understanding-causes-intravenous-medication-administration-errors-hospitals- qualitative The critical incident technique … understanding-causes-intravenous-medication-administration-errors-hospitals-qualitative https://psnet.ahrq.gov/issue/critical-incident-technique

43. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43188/psn-pdf
    May 21, 2014 - This educational study found that anesthesiology residents were more likely to initiate an airway technique … for which they had received simulation training, even if another technique (for which they received

44. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/38436/psn-pdf
    February 25, 2009 - of inking needle core prostate biopsies for preventing patient specimen identification errors: a technique … effectiveness of inking needle core prostate biopsies for preventing patient specimen identification errors: a technique

45. Healthcare Failure Mode and Effect Analysis. | PSNet
    psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis
    May 24, 2017 - healthcare failure mode and effect analysis (HFMEA), the steps of the HFMEA process, and how to apply the technique … Patient Safety Innovations Combined Proactive Risk Assessment (CPRA) – 4-Step Technique

46. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45500/psn-pdf
    September 28, 2016 - potentially inappropriate prescribing in children (PIPc) in primary care using a modified Delphi technique … of potentially inappropriate prescribing in children (PIPc) in primary care using a modified Delphi technique

47. Training induces cognitive bias: the case of a simulation-based emergency airway curriculum. | PSNet
    psnet.ahrq.gov/issue/training-induces-cognitive-bias-case-simulation-based-emergency-airway-curriculum
    May 18, 2022 - This educational study found that anesthesiology residents were more likely to initiate an airway technique … for which they had received simulation training , even if another technique (for which they received

48. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/857059/psn-pdf
    November 29, 2023 - The surgeon placed the PEG tube in the intensive care unit (ICU) using the “pull technique” (i.e., via … A “safe track” technique with endoscopic visualization of a fine 25-gauge “finder” needle puncturing … In this case, the PEG was removed via traction technique about 4 months after its placement. … Gastrostomy without laparotomy: a percutaneous endoscopic technique. … Percutaneous endoscopic gastrostomy: indications, technique, complications and management.

49. Human patient simulation: teaching students to provide safe care. | PSNet
    psnet.ahrq.gov/issue/human-patient-simulation-teaching-students-provide-safe-care
    June 24, 2009 - from their experience using simulation to teach safety skills to nursing students and illustrate the technique … December 9, 2009 The SBAR communication technique: teaching nursing students professional

50. Submit Innovations Landing | PSNet
    psnet.ahrq.gov/submit-innovations-landing
    February 26, 2025 - Innovation Examples INNOVATION Combined Proactive Risk Assessment (CPRA) – 4-Step Technique … the Veteran Health Administration (VHA) National Center for Patient Safety (NCPS) development of a technique

51. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/72517/psn-pdf
    November 25, 2020 - , can be effective in high-stress or fraught circumstances.13 The value of this technique comes from … This technique, adapted from the military and then modified for use at Kaiser Permanente,14 has been … and physician-physician interactions.17 A systematic review of SBAR handoffs demonstrated that the technique … .18 There is evidence that use of the SBAR technique improves both the perception of communication between … "SBAR Technique for Communication: A Situational Briefing Model".?www.ihi.org. Retrieved?

52. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet
    psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
    August 01, 2012 - The surgeon placed the PEG tube in the intensive care unit (ICU) using the “pull technique” (i.e., via … ” (Figures 1 and 2) or a “push technique,” depending on available supplies and proceduralist preference … In this case, the PEG was removed via traction technique about 4 months after its placement. … Gastrostomy without laparotomy: a percutaneous endoscopic technique. … Percutaneous endoscopic gastrostomy: indications, technique, complications and management.

53. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/74251/psn-pdf
    January 26, 2022 - In this patient, an injury to the intercostal artery suggests that the technique utilized to insert … Standard well-accepted thoracostomy technique involves dissection and tube placement immediately superior … Approach to Improving Patient Safety Errors in both judgement and technique led to this adverse outcome … External Jugular Cutdown Technique for Totally Implantable Venous Access Devices: a Single-Centre Study … Hickman central venous catheters in children: open versus percutaneous technique. 

54. Measuring faculty reflection on adverse patient events: development and initial validation of a case-based learning system. | PSNet
    psnet.ahrq.gov/issue/measuring-faculty-reflection-adverse-patient-events-development-and-initial-validation-case
    September 20, 2011 - Reflection, or thinking about thinking, is often used as a technique to encourage learning from adverse … Patient Safety Innovations Combined Proactive Risk Assessment (CPRA) – 4-Step Technique

55. Improvement Tools | PSNet
    psnet.ahrq.gov/improvement-tools
    February 26, 2025 - All Innovations INNOVATION Combined Proactive Risk Assessment (CPRA) – 4-Step Technique … the Veteran Health Administration (VHA) National Center for Patient Safety (NCPS) development of a technique

56. A systems approach to analyzing and preventing hospital adverse events. | PSNet
    psnet.ahrq.gov/issue/systems-approach-analyzing-and-preventing-hospital-adverse-events
    March 30, 2022 - This article describes the use of a new accident analysis technique (CAST, or Causal Analysis based on … This technique can be useful in identifying causal factors to help health care systems learn   from

57. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. | PSNet
    psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
    November 30, 2021 - communications, such as use of the SBAR ( Situation, Background, Assessment, and Recommendations ) technique … , can be effective in high-stress or fraught circumstances. 13 The value of this technique comes from … This technique, adapted from the military and then modified for use at Kaiser Permanente, 14 has been … . 18 There is evidence that use of the SBAR technique improves both the perception of communication … "SBAR Technique for Communication: A Situational Briefing Model" .  www.ihi.org .

58. Using medical-error reporting to drive patient safety efforts. | PSNet
    psnet.ahrq.gov/issue/using-medical-error-reporting-drive-patient-safety-efforts
    September 18, 2024 - September 18, 2024 Safety on the ground: using critical incident technique to explore … Patient Safety Innovations Combined Proactive Risk Assessment (CPRA) – 4-Step Technique

59. The problem with the '5 whys.' | PSNet
    psnet.ahrq.gov/issue/problem-5-whys
    July 19, 2023 - August 20, 2014 Beyond FMEA: the structured what-if technique (SWIFT). … Patient Safety Innovations Combined Proactive Risk Assessment (CPRA) – 4-Step Technique

60. Patient safety: this is public health. | PSNet
    psnet.ahrq.gov/issue/patient-safety-public-health
    July 19, 2023 - July 7, 2021 Beyond FMEA: the structured what-if technique (SWIFT). … Patient Safety Innovations Combined Proactive Risk Assessment (CPRA) – 4-Step Technique