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psnet.ahrq.gov/node/60865/psn-pdf
August 31, 2020 - We are humans interacting with humans, which means we're going to make mistakes. … We know who's going to be doing the right thing and have the integrity of doing it when
nobody is looking … That person is Sam W., a 21-year-old man who wanted to be a
paramedic and that wasn't going to be an … For
example, instead of having a rehab goal of walking 50 feet with the pulse oximeter not going below … to make a mistake and that mistake is going to harm somebody's mother, brother,
father, sister.
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psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
May 14, 2020 - Really thinking about how population management is going to be done, how telehealth can be integrated … I think there are going to be some potential improvements for patient safety from that perspective. … If you’re bad at that in person, you are going to be worse with telemedicine. … We know that 80% of what is going on with the patient is in the medical history. … On some level, it’s going to be practice dependent and provider dependent.
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - KH: And so for your Learning Lab work, it’s really focused around that first week after going home? … Otherwise, they are not going to call when they're concerned, they're not going to call until it’s a … We're going to do workshops with nurses and providers and then with patients to think about how we’re … going to explain this important stuff—what are the elements and then how are those presented? … Now that you are starting to have these data, what are you going to do with it?
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psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
October 06, 2021 - KH: And so for your Learning Lab work, it’s really focused around that first week after going home? … Otherwise, they are not going to call when they're concerned, they're not going to call until it’s a … We're going to do workshops with nurses and providers and then with patients to think about how we’re … going to explain this important stuff—what are the elements and then how are those presented? … Now that you are starting to have these data, what are you going to do with it?
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psnet.ahrq.gov/node/33660/psn-pdf
December 01, 2007 - system is having
appropriate measurement in place so that we can actually judge whether things are going … EC: Most solutions are going to be local. … At
each opportunity, the coach encourages the patient to speak up, even going as far as giving them … Again,
the coach isn't going to solve all the discrepancies, but the coach needs at least to be able … EC: We have sought out experts across the country to help us in our thinking, even going as far as
preparing
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psnet.ahrq.gov/node/33704/psn-pdf
December 01, 2010 - If I admit to you that I don't know if I did wrong, or I did do wrong, or we don't know what's going … on, we have a belief system that people are going to sue us. … Somebody's going to find out
and want the story. … One of your employees is going to call somebody at the paper or television station. … And if something goes wrong,
then say, "Well, we're going to work on that, too."
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psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
March 10, 2021 - If you're going to really do that, then you have to build it into the budgets, you have to make space … They're going to their advisors and saying we need you to help us design and evaluate our telehealth … systems are putting dollars behind this as a way to indicate that they are serious, but they’re also going … A once-a-month PFAC meeting is going to continue because that can be a very good anchor, but we have … Are you going to just start doing this?
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psnet.ahrq.gov/issue/our-long-journey-towards-safety-minded-just-culture-part-i-where-weve-been
November 13, 2018 - Part II: where we're going. … Part II: where we're going.
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psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc
June 12, 2019 - If a safety intervention is going to work, it has to be practical. … Not every single hospital is going to have an extremely motivated and focused team that is going to develop … If something is going to work and people believe it will, then it probably makes sense to mandate its … If a friend or family member of yours calls you, says he or she is going in for surgery and the surgeon … RW : Any sense of where this issue is going to go in the future?
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psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - The change in paradigm is going to encourage radiologists to slow down and take more time to ensure they … make fewer mistakes, but it’s not going to make the volume of work go away. … AI is not going to be reading an MRI of the abdomen instead of a radiologist any time soon. … KH: Do you think AI is a passing trend that is going to be too overwhelming to adopt in the long-term … That is all to say I don’t think AI is going away. This is here. This is now.
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psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
March 30, 2020 - We also don’t understand the connection between hospitals and the ambulatory space and that’s going to … It’s also interesting to think about if we’re going to abandon some practices because they failed. … We thought that was going to be the answer, but later figured out it was not the best approach. … You’re going to turn to it often to see where the state of the art is, and then go deeper from there … BS: I’m going to echo something that Ann said earlier, I think that the delirium piece is undervalued
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psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
March 30, 2020 - We also don’t understand the connection between hospitals and the ambulatory space and that’s going to … It’s also interesting to think about if we’re going to abandon some practices because they failed. … We thought that was going to be the answer, but later figured out it was not the best approach. … You’re going to turn to it often to see where the state of the art is, and then go deeper from there … BS: I’m going to echo something that Ann said earlier, I think that the delirium piece is undervalued
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psnet.ahrq.gov/node/33742/psn-pdf
December 01, 2012 - They're a little hyponatremic, going into renal failure, and
on medications that maybe the doctor has … You have to very thoughtfully look through
everything and it's probably not going to be solved by just … But right now the only way to reliably identify
the delirium is from someone going to the bedside. … We're going to have national guidelines for delirium within 2 years. … So there is a lot of stuff
going on. It's just as you know, a very, very slow process.
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psnet.ahrq.gov/node/33774/psn-pdf
December 01, 2014 - same thing
you've been trying to do which is give people the best quality care possible, but we're going … In some
countries that's going to mean putting electronic health records in people's hands, giving them … It's just not going to happen, or not going to happen easily. … Now I see in many countries there's
going to be a big global focus on what the international community … Every new
hospital that they opened would start with discussions from the patients that were going to
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psnet.ahrq.gov/perspective/conversation-withsorrel-king
March 01, 2007 - We were going to give the money to cancer research for children, build a playground for kids with cancer … These systems are eventually going to break down and something is going to happen that wasn't that doctor's … But something bad is going to happen and it's going to look like it's that person's fault or that person … is going to feel like it was their fault that they hurt this patient. … That's why we keep going on with what we're doing.
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psnet.ahrq.gov/node/33877/psn-pdf
April 01, 2019 - that we know our care was bad, but the message from our
leadership, including legal, was we're still going … to follow that
data as closely as possible to see how well the automated reporting work seems to be going … Often you'll
hear people say, "I'm going to iVOS you before you iVOS me." … The physicians learned this is a great number to call because
you're going to get all that support. … The default position is going into the Joe Friday "just
the facts" mode.
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psnet.ahrq.gov/node/33702/psn-pdf
November 01, 2010 - Once we had identified these candidate indicators both from literature review and from going through … RW: If you were a patient thinking about going to a hospital, how would you figure out whether it was … It has to be viewed in the context of what's going on in terms of quality
improvement, what's going … Going forward, I think AHRQ is trying to figure out how
to align these different pathways. … I think these trends are converging, and going
forward I'm hoping that it will be easier for hospitals
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psnet.ahrq.gov/perspective/meaningful-measurement-patient-and-family-engagement
March 10, 2021 - If you're going to really do that, then you have to build it into the budgets, you have to make space … They're going to their advisors and saying we need you to help us design and evaluate our telehealth … systems are putting dollars behind this as a way to indicate that they are serious, but they’re also going … A once-a-month PFAC meeting is going to continue because that can be a very good anchor, but we have … Are you going to just start doing this?
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psnet.ahrq.gov/perspective/conversation-susan-smith-md
August 01, 2019 - The first is to make sure that the work going directly to the physician really can only be done by the … Once we started having a scribe for physicians, the idea that we were going to take away the scribe was … That was not going to happen. … "Right now we're just going to do the exam." … My underlying principle would be that if it's more fun, people are going to enjoy themselves more and
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psnet.ahrq.gov/node/61083/psn-pdf
October 28, 2020 - Nursing homes have slowly become aware that
things like fee-for-service are going away and they need … LP: When we went into lockdown, we thought, it is going to slow down, we are going to come out of it; … We’re going to see more deaths from isolation than COVID-19. … If we have another big spike, is the supply chain
going forward going to remain sufficient? … And the one party you forget about is the one that is going to screw you
https://echo.unm.edu/about-echo