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psnet.ahrq.gov/node/33720/psn-pdf
November 01, 2011 - RW: Sometimes people bring up the idea that, for example, a cockpit really only has two or three people … at
fairly similar levels of the organization and hierarchy that have to be able to speak up to each … health care a team might have 20 or 30 people, very fluid, and it might be a clerk who has to speak up … RW: As you bring up pattern recognition and chess players, earlier this year a computer beat the Jeopardy
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psnet.ahrq.gov/node/33734/psn-pdf
August 01, 2012 - the survey that reflect staffing issues and transition
between unit issues—similar to what we picked up … So again we're coming up with the conclusion that, at least in
comparison to hospitals, nursing homes … RW: What keeps you up at night as you think about the aging population in terms of nursing home care … It is not a
matter of just housing residents in a room and watching TV all day or lining them up in
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psnet.ahrq.gov/node/866622/psn-pdf
August 28, 2024 - recognition of an individual’s helpful actions, we
promote psychological safety that helps people speak up … Safety-I approach, we heard from team members that there was often not psychological
safety to speak up … For example, feedback from team members indicated discomfort with
speaking up in traditional post-event … well and how compassionately you
facilitate an event review or an RCA, sometimes the walls are still up
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psnet.ahrq.gov/node/33841/psn-pdf
September 01, 2017 - We would go down to radiology to put up the films with the
radiologist; we were unable to do anything … you'd have to leave that with a bunch of keystrokes and go into the lab part of the system to
look up … If something comes up and it doesn't
make sense, just because the computer presented it to you doesn't … A lot of times, regulation that starts out in a very well-
meaning way ends up not really achieving … Is it up and running? Is it a thing today?
AG: No, and I've been very public about this.
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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - students feel when they witness an error and struggle with the questions of whether and how to bring up … This is certainly the message this student received from the first attending when he finally spoke up … and gently critiqued had the attending simply said, “I really appreciate you bringing this concern up … About five hands went up. We have a long way to go. … Until we take up this work and find the resources to support it, we will lack a culture of safety, and
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psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - The syringe used for spinal injection is usually not
labelled because medications are drawn up on the … In anesthesia, an error as simple as forgetting to flick a switch or to open a valve can
end up being … shift the previous day, they should be allowed to go home early the next day so that they can catch up … check the label on all ampules
The anesthesiologist is usually wearing sterile gloves when drawing up
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psnet.ahrq.gov/node/33656/psn-pdf
September 01, 2007 - take care of high volumes of kids with cystic fibrosis, they have well-
trained specialists, they follow … As a teaching institution, we have to end up teaching surgeons and doctors, and we have to be
able to … the operating room they never witness from
my generation of surgeons what they still sometimes put up … generally find is that I read
something in the paper or have a conversation with someone, and it opens up
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psnet.ahrq.gov/web-mm/code-blue-where
March 30, 2020 - flights of stairs, outside the front of the hospital, down the block, into the psychiatry facility, and up … When the critical care nurse and the rest of the code team arrived, they attempted to hook the patient up … defibrillation (T defib ) is the single most important variable associated with survival, as mortality increases up … Follow American Heart Association (AHA) Public Access Defibrillation (PAD) program policies Expensive
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psnet.ahrq.gov/node/33694/psn-pdf
April 01, 2010 - harmonize measures—for example, to make sure that all of the measures in the
area of immunizations follow … RW: I imagine that the never-ending process of coming up with new measures, while dealing with an ever … Now we're coming up on the decade anniversary of both reports.
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psnet.ahrq.gov/node/49410/psn-pdf
July 01, 2003 - Apply ophthalmic ointment to the eye and affected lashes, patch
the eye closed, and arrange for follow-up
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - their medication regimens
confusing or complicated, especially if not given clear instructions about follow-up … reconciliation on
admission and discharge, ensuring access to care after discharge, and post-discharge follow-up
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psnet.ahrq.gov/node/49627/psn-pdf
June 01, 2011 - I was a bit shaken up and because I was not sure of the cause, I took her to see her
pediatrician. … exam on his wife when she complained of
pain shortly after suffering an apparent miscarriage, coming up
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - admitted to an intensive care unit (ICU) in the United States will be transferred to a different ICU
Up … Adverse events may occur in 1%–34% of critical care transfers
While the mortality rate remains low, up
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psnet.ahrq.gov/web-mm/surprise-wire
July 15, 2020 - Author(s)
Cumulative effect of flexible duty-hour policies on resident outcomes: long-term follow-up … February 1, 2007
WebM&M Cases
Citrate Mix-Up
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psnet.ahrq.gov/web-mm/easily-forgotten-tube
June 01, 2016 - Each device can be used for up to 29 days. … WebM&M Cases
Procedure Complications – Who is Responsible for Follow … up?
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psnet.ahrq.gov/node/73999/psn-pdf
October 27, 2021 - psnet.ahrq.gov//#3
https://psnet.ahrq.gov//#3
https://psnet.ahrq.gov//#6
https://psnet.ahrq.gov//#6
Drawing up … medication errors or near-misses.1,5,9 Staff should be encouraged to report these occurrences and a
follow-up
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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - technology or flawed systems design; lack of evidence for effectiveness of solutions; insufficient follow-up … Maternal Safety
January 31, 2024
Predictors of likelihood of speaking up
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psnet.ahrq.gov/node/33704/psn-pdf
December 01, 2010 - I think we have a whole group of physicians
who grew up with that belief system and who trained the … Now with the
younger physicians growing up in an environment where it's okay to admit that we're human—that … Those billable hours and the drive to contingency add up. … When we don't live up to our own expectations for
ourselves as professionals, it is painful. … I follow [health care reporter] Larry Tye's recommendation: know who your local media are and
let them
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psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
November 21, 2021 - Unfortunately, these alerts have not yet lived up to expectations. … Resources
WebM&M Cases
Critical Echocardiogram Result Lost to Follow-up
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psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
August 31, 2020 - content, such as I-PASS , TeamSTEPPS , simulation-based closed-loop communication , and speaking up … on using a combination of patient/family-centered HIT and pharmacist-led counseling, coaching, and follow-up