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Total Results: 1,064 records

Showing results for "ultimately".

81. 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

82. 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

83. In Conversation With… John D. Birkmeyer, MD | PSNet
    psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
    January 31, 2024 - It was only afterward, as they participated in the process of rating their peers and they ultimately … But then, a couple of videos later, I was sampling recordings of surgeons that ultimately rated at the … However, I never imagined for a second that it would be as powerfully associated with outcomes as ultimately … I believe that that ultimately will hold true for operative surgery as well. … can use big data approaches to assessing spatial movements of instruments that appear on a screen and ultimately

84. 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.

85. Hospital ward incidents through the eyes of nurses – a thick description on the appeal and deadlock of incident reporting systems. | PSNet
    psnet.ahrq.gov/issue/hospital-ward-incidents-through-eyes-nurses-thick-description-appeal-and-deadlock-incident
    November 15, 2023 - struggle to define “report-worthy” events and question whether actions stemming from incident reports ultimately

86. 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

87. 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

88. Blaming others for threatening events. | PSNet
    psnet.ahrq.gov/issue/blaming-others-threatening-events
    November 25, 2009 - and personal characteristics, with interpersonal and intrapersonal mediators playing a role, which ultimately

89. Impact of fatigue and insufficient sleep on physician and patient outcomes: a systematic review. | PSNet
    psnet.ahrq.gov/issue/impact-fatigue-and-insufficient-sleep-physician-and-patient-outcomes-systematic-review
    October 19, 2022 - They ultimately included 47 studies in their analysis, 28 of which demonstrated a relationship between

90. How physicians think: a case-based diagnostic simulation exercise. | PSNet
    psnet.ahrq.gov/issue/how-physicians-think-case-based-diagnostic-simulation-exercise
    August 14, 2019 - use of a case-based simulation to explore how physicians reason, create differential diagnoses, and ultimately

91. The (commercialised) experience of operating: embodied preferences, ambiguous variations and explaining widespread patient harm. | PSNet
    psnet.ahrq.gov/issue/commercialised-experience-operating-embodied-preferences-ambiguous-variations-and-explaining
    August 24, 2022 - describe their preferences for and experiences with a device which caused widespread harm to women and was ultimately

92. Misdiagnosis of thoracic aortic emergencies occurs frequently among transfers to aortic referral centers: an analysis of over 3700 patients. | PSNet
    psnet.ahrq.gov/issue/misdiagnosis-thoracic-aortic-emergencies-occurs-frequently-among-transfers-aortic-referral
    October 28, 2020 - transfers present their own risks, these researchers evaluated emergency transfers of patients who did not ultimately

93. The intersection of traumatic childbirth and obstetric racism: a qualitative study. | PSNet
    psnet.ahrq.gov/issue/intersection-traumatic-childbirth-and-obstetric-racism-qualitative-study
    June 14, 2023 - Ultimately these experiences caused long-term harm to their mental health, decreased trust in healthcare

94. Quality improvement as a primary approach to change in healthcare: a precarious, self-limiting choice? | PSNet
    psnet.ahrq.gov/issue/quality-improvement-primary-approach-change-healthcare-precarious-self-limiting-choice
    June 08, 2022 - harm” goals) over participants’ emotional experience and sociotechnical design elements, which can ultimately

95. Career impact of the chief resident in quality and safety training program: an alumni evaluation | PSNet
    psnet.ahrq.gov/issue/career-impact-chief-resident-quality-and-safety-training-program-alumni-evaluation
    June 19, 2019 - suggests that such programs can teach residents to lead and engage other residents in patient safety and ultimately

96. Medical bias: from pain pills to COVID-19, racial discrimination in health care festers. | PSNet
    psnet.ahrq.gov/issue/medical-bias-pain-pills-covid-19-racial-discrimination-health-care-festers
    June 24, 2020 - This story examines how racial bias  can affect diagnosis, research, and treatment, ultimately resulting

97. 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

98. Safety incidents in family medicine. | PSNet
    psnet.ahrq.gov/issue/safety-incidents-family-medicine
    December 11, 2013 - reporting system, designed to encourage error reporting in ambulatory family medicine practices, ultimately

99. 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

100. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33785/psn-pdf
     May 01, 2015 - It was only afterward, as they participated in the process of rating their peers and they ultimately … But then, a couple of videos later, I was sampling recordings of surgeons that ultimately rated at the … However, I never imagined for a second that it would be as powerfully associated with outcomes as ultimately … I believe that that ultimately will hold true for operative surgery as well. … use big data approaches to assessing spatial movements of instruments that appear on a screen and ultimately