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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43937/psn-pdf
    May 05, 2018 - /issue/targeted-medication-safety-best-practices-hospitals https://psnet.ahrq.gov/issue/group-urges-going-metric-head-dosing-mistakes
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46915/psn-pdf
    April 16, 2018 - review discusses the development of the RIGHTT mnemonic (Risk for adverse event, Insight into pain, Going
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33744/psn-pdf
    February 01, 2013 - That approach by health care professionals is not going to keep people safe. … It's not going to result in the best outcomes. … A clinician can say, "I'm going to be talking about some options and teaching our trainees." … But it is also that they can and should, I'm going to say confront for lack of a more delicate word, … that I cared more about my health than anyone else, and that I needed to be careful about who was going
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33714/psn-pdf
    July 01, 2011 - That also gave us the opportunity to say, we're going to define a system that doesn't work just at the … RW: You are in a position where you're likely going to be asked to report something about rates of safety … events, even though in a voluntary system those are always going to be biased. … get collected unless one has already decided exactly why it's important to collect it, and how it's going … Any data that might be collected—if it's not going to be used in a report, we don't collect it.
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33678/psn-pdf
    January 01, 2009 - If you're going to offer an apology, should it be an expression of regret ("I'm sorry about what happened … This is a shift we're going to see over the next few years—more and more disclosure being considered … patient on your watch experienced a terrible medication error and was now in the ICU, and you were going … It involves going in, quickly ascertaining what the patient knows about what's happened, and then, in … Then let the patient know we're going to look into this event carefully and we'll be back in touch to
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73145/psn-pdf
    April 28, 2021 - I think it's going to have better outcomes. … It takes a lot of work, but it's work that is mandatory if we’re going to have a successful program … KH: Going back to the patient and the care partner education, that sounds like a pretty important part … I think anything we can do to help alleviate some of that burden through technology is going to be very … JAM:  Kidney disease isn't going away, and I think when we are looking at treatment options, we have
  7. psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
    May 31, 2023 - to learn that having enough faculty and frontline providers on board to engage in that process was going … But even before this degree of involvement—and even before we knew that we were going to have the federal … AS : The concern was that it was going to take a lot longer. … I foresee that's going to continue to improve with time. … That's always going to be an important piece. We can't get rid of people!
  8. psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md
    June 01, 2018 - We also made it clear from the beginning that this was going to be about education. … AI is going to be a tool we will use, and we should apply the technology to both education and clinical … Where people are in some ways going beyond what either they or the technology are capable of doing? … What is going to take more extensive training? … We know some practitioners are going to extend their practice beyond their knowledge and skill levels
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33682/psn-pdf
    April 01, 2009 - Which one is going to be lethal tomorrow? … So if you're going to use an outcome as a valid measure of quality, you must have a proven relationship … Ultimately, that is what it is going to take if we are going to meet the expectations of the public, … RW: One of the things I hear from hospitals is that they understand they are going to be measured, accredited
  10. psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
    October 01, 2008 - So if the hospital is going to be tagged with an adverse event that happened at another place, that's … So we're going to have to have the equivalent of the Hertz guy walking around the patients looking at … I don't think that's what Medicare intends, but I think that's the risk of going too far and too fast … RW: The overall policy direction is so sensible that I cannot see it going away. … That's where we need to be investing if we're going to promote patient safety.
  11. psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
    March 01, 2017 - Or examples of things going right that seem very obvious to me, in the same ways we don't learn about … So if we're going to implement something, we have to know this thing actually works. … No two interventions are going to be exactly the same in how you implement them. … MDW : That is, in fact, where my current research program is going. … RW : I guess the question going forward is the same scaling question.
  12. psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
    June 01, 2010 - problem analysis and resolution; 5 , 15 and (iv) provision of follow-up, patient education, and on-going … Once I became aware of things that were going wrong, I began to look outside of medicine and to other … What's going through your brain that's not going through that person's brain? … PC: When I came into emergency medicine, nobody sat me down and said, this is what your life is going … To be frank with people and let them know what's coming and the sorts of failures that they're going
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33706/psn-pdf
    February 01, 2011 - And what I discovered is that they were never going to change because of me. … They were never going to respond to Intermountain. … I can't tell you how gratified I feel to see my students going out and changing the world. … This is one of those tipping point phenomena, and it's going to pick up a lot more speed as it moves … But that as your education level comes up, fundamentally, senior management doesn't know what's going
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861881/psn-pdf
    January 31, 2024 - Can you tell them what’s really going on in your life, with your health, and also day-to-day factors … their clinic for 6 or 7 weeks, and then finally a nurse asked the patient, “How is your chemotherapy going … And the patient said, “I’m not really getting anything else; I’m not going anywhere else. … Whether it’s going to the patient’s home or calling them, or video conferencing, and really following … In my opinion, if nursing doesn’t do it, eventually, I believe the healthcare system is going to find
  15. psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
    February 26, 2025 - You're not doing anyone a favor by rigorously evaluating something that's not going to work. … Then if it looks like it's promising—if it's going to be an accreditation standard or some other widely … RW : I have residents in our M&M say that "Here's what I thought was going on, but I was worried that … The electronic strategies now have created a larger group of people who can keep up with what's going … But what are you going to do if you're in patient safety?
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845472/psn-pdf
    March 15, 2023 - You have to provide a clear expectation that while these data are going to come to us right away, a … For the most part, the medical devices are accurate, and the values are going to be similar. … Neal Sikka: On the protocol side, patient selection is important on the front end: Who is really going … From there, you need to know what types of trained staff are going to monitor that data. … We had staff in place and knew this was going to be different from hypertension monitoring where you
  17. psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
    January 31, 2024 - RW : I might have envisioned trying to have your own people going into all these surgeons' ORs to film … removing all of the measurement noise associated with some cases being harder than others and some cases going … well and others going poorly. … the surgeons that agreed to participate in this study went into this study thinking that they were going … RW : If you were a patient and you saw those videos, you would be quite scared that you were going to
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50392/psn-pdf
    September 01, 2019 - They're a great source of intelligence about what's going on in quality and the greatest needs. … I remember those early days of trying to figure out if you were going to focus on certain safety targets … the most sense and then trying to optimize those measures as best as possible, realizing we are not going … the data out of all of these systems and give you a coherent picture as a clinician about what is going … What do you say to both groups and do you think the future is going to be better in both of those domains
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33806/psn-pdf
    April 01, 2016 - to learn that having enough faculty and frontline providers on board to engage in that process was going … But even before this degree of involvement—and even before we knew that we were going to have the federal … AS: The concern was that it was going to take a lot longer. … I foresee that's going to continue to improve with time. … That's always going to be an important piece. We can't get rid of people!
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33664/psn-pdf
    March 01, 2008 - RW: Some places that have read about your work are going to try to begin a service that looks like yours … based on where the patients are located, how hard it is to move them, and what kind of procedure we're going … right, how to adapt, and what other maneuvers or adjustments you can do so that the procedure ends up going … This is just my opinion, but I think if you drop down below 50% of your time doing procedures, you're going … morning in the ICU, if a patient is crashing and needs a line for pressors or blood products, it's going

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