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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - steady since 1998, at around 40,000 cases annually.( 1,2 ) About one quarter of infected persons are thought
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - Dysarthria: If patient is thought to be normal, an
adequate sample of speech must be obtained by asking
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psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
March 01, 2018 - RW : One would have thought that in every other industry, you bring in technology and you need fewer
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psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
January 29, 2021 - of trauma) is now well recognized and has been labeled “well leg compartment syndrome”. 7,8,9 It is thought
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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - Both admissions were thought to be triggered by hypoxia secondary to being off home oxygen in the setting
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psnet.ahrq.gov/perspective/conversation-cindy-brach
December 27, 2019 - Then you need to be thinking about language banks, language lines, and where do you need community health … December 27, 2019
Background Culture can be defined as the “personal identification, language, thoughts
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psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
April 01, 2013 - Robert Wachter, Editor, AHRQ WebM&M : Tell us how your thinking about duty hours and patient safety has … In terms of how my thinking has changed, for one thing, we know a lot more now than we did 10 years ago … In my view, this thinking is wrong. … CL : I have a couple of thoughts about that.
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
July 30, 2020 - Biases in the Diagnostic Process Clinician decision-making often relies on cognitive thought processes—called … It entails switching from “automatic thinking” (also called “intuitive” or System 1 reasoning ) to more … “reflective thinking” (also called “analytical” or System 2 reasoning), informed by communication
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - SPOTLIGHT CASE
What Happened on Telemetry?
Citation Text:
Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNo…
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx
Spotlight
Overdose of Gabapentin and Oxycodone in a Patient
with End-Stage Renal Disease: A Case for Appropriate
Interruptive Drug-Disease Alerts
Source and Credits
• This presentation is based on the January 2023 AHRQ WebM&M
Spotli…
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psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
November 02, 2016 - Promising Areas for Patient Safety Research
P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH | December 1, 2003
View more articles from the same authors.
Citation Text:
Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. …
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psnet.ahrq.gov/node/33768/psn-pdf
June 01, 2014 - Was that a choice on your part because that was what you thought had the
best chance to be successful … I learned that if
you understand structural thinking—if you understand feedback loops and the cultural … There are many
times when I want to smack someone on the side of the head and say, "What are you thinking
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - Our Society [SIDM] thought if we
could convince the IOM to undertake a major report on diagnostic error … Where
did that come out in the committee's deliberations, and what are your thoughts about that? … This is where we document our thoughts, find our information, and communicate with others.
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psnet.ahrq.gov/node/836877/psn-pdf
May 16, 2022 - Remle Crowe: Right, we thought this one was really important, because that handoff is so critical. … Just thinking kind of broadly about, what are the primary events that are being experienced in prehospital … Thinking back to
when you started, and all the way through your career now, is there anything that you … So when you're under pressure and you're thinking about which button to
push, you may actually push
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - ://www.sprc.org/settings/primary-care/toolkit .( 11,12 ) Importantly, suicidal ideation (defined as thinking … If a patient expresses suicidal thoughts but the nature of the intent and plan is not clear, asking about … exposure (peer or celebrity) Access to lethal means Cognitive rigidity (perfectionistic, black or white thinking … Warning signs (thoughts, behaviors, situations) Internal coping mechanisms People/social settings that
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psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
March 01, 2019 - They should be educated in systems thinking associated with modern patient safety best practices and … This onboarding, as well as ongoing educational efforts focused on systems thinking, change management
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psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
January 01, 2014 - I am always thinking about what's next and how are we going to support future research. … was an opportunity to write a first author paper on a related topic, I would take it if my mentors thought … the augmentation of performance that occurs when clinicians shift from automatic to more reflective thinking … Summary
Taken together, the literature published in 2014 represents a significant advance in our thinking … is clear that the patient safety movement has targeted medical education as an area in need of new thinking
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psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
June 01, 2004 - The neurology and neurosurgical teams thought that if the brain swelling had been recognized at the time