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Total Results: 1,018 records

Showing results for "ultimately".

61. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/44056/psn-pdf
    May 19, 2018 - This study relied on complicated cost accounting and statistical modeling, ultimately using three different

62. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/34763/psn-pdf
    March 07, 2005 - In fact, Sagan ultimately concludes that good fortune played a greater role than good design in the

63. User's manual for the IOM's 'Quality Chasm' report. | PSNet
    psnet.ahrq.gov/issue/users-manual-ioms-quality-chasm-report
    August 04, 2021 - experience of patients, functioning of microsystems and organizations, and environmental factors), and ultimately

64. A case of adverse drug reaction induced by dispensing error. | PSNet
    psnet.ahrq.gov/issue/case-adverse-drug-reaction-induced-dispensing-error
    August 17, 2022 - mistakenly taking two contraindicated medications, which resulted in an adverse drug reaction and ultimately

65. The foundational science of learning health systems. | PSNet
    psnet.ahrq.gov/issue/foundational-science-learning-health-systems
    June 26, 2019 - networks, and processes to use data, information, evidence, and knowledge to implement change and, ultimately

66. Does a unit shift report "blackout" period improve patient safety? | PSNet
    psnet.ahrq.gov/issue/does-unit-shift-report-blackout-period-improve-patient-safety
    August 04, 2021 - The project did devise a standardized handoff process that was ultimately employed across the organization

67. Managing the Risks of Organizational Accidents. | PSNet
    psnet.ahrq.gov/issue/managing-risks-organizational-accidents
    May 13, 2011 - this book demonstrates Reason's thinking at its finest and illustrates many of the key concepts that ultimately

68. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33821/psn-pdf
    December 01, 2016 - industries, primarily aviation.(3,4) Perhaps the most powerful ambition was that health care systems would ultimately … practical difficulty is resolving the inherent ambiguity in near-miss events: does the fact that there was ultimately

69. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37791/psn-pdf
    September 29, 2017 - Ultimately, the decision was overturned by OHRP (with considerable pressure from those in the safety

70. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/47452/psn-pdf
    December 27, 2018 - From the 144 studies ultimately included in the analysis, they found that implementation of evidence-based

71. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/40692/psn-pdf
    October 04, 2011 - for patients with obesity are discussed in an AHRQ WebM&M commentary, which examined a case of an ultimately

72. In Conversation With… Amy J. Starmer, MD, MPH | PSNet
    psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
    May 31, 2023 - The success of that single-center study ultimately led to the multicenter I-PASS study . … We ultimately landed on I-PASS, which stands for I llness severity, P atient summary, A ction list … Of course, we ultimately found that there was not any significant difference in the amount of time that … This synthesis component was an initially resisted yet ultimately highly valued behavior change that

73. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33578/psn-pdf
    September 15, 2024 - Each of these safety hazards ultimately was attributed to a relatively simple yet overlooked problem … This workaround was deemed to be a substantial contributor to the ultimately fatal error.

74. Delayed Diagnosis of Kidney Transplant Complications | PSNet
    psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
    January 29, 2020 - identified a hematoma that was likely related to the radiology procedure as well as decreased flow that was ultimately … features that would have led to earlier confirmatory imaging with magnetic resonance angiography, which ultimately … imaging and subsequent CT imaging delayed the diagnosis and management of the renal artery stenosis that ultimately

75. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/38455/psn-pdf
    January 02, 2017 - The guidelines also required timely discussion with an attending physician, which ultimately led to

76. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/41257/psn-pdf
    April 22, 2012 - A set of 20 domains were ultimately outlined with most studies identifying individual factors, communication

77. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/48125/psn-pdf
    July 24, 2019 - expressed concern that physicians who train for fewer hours will leave residency less skilled and ultimately

78. Making Just Culture a Reality: One Organization's Approach | PSNet
    psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
    October 01, 2007 - But the tension was ultimately that individuals played a role. … But ultimately, errors are going to occur. … The second category is at-risk behavior—that is, taking shortcuts that ultimately lead to increased risk … Organizations must educate the professionals in the workforce to understand the risks, and ultimately … Some physician leaders, in particular, believe that the just culture model will ultimately lead to tort

79. Updating Eindhoven: clarifying the features of a patient safety near miss. | PSNet
    psnet.ahrq.gov/issue/updating-eindhoven-clarifying-features-patient-safety-near-miss
    March 13, 2024 - misses and close calls are patient safety events that have the potential to cause patient harm but ultimately

80. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33806/psn-pdf
    April 01, 2016 - The success of that single- center study ultimately led to the multicenter I-PASS study. … We ultimately https://psnet.ahrq.gov/issue/development-and-implementation-oral-sign-out-skills-curriculum … Of course, we ultimately found that there was not any significant difference in the amount of time that … This synthesis component was an initially resisted yet ultimately highly valued behavior change that