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psnet.ahrq.gov/node/33783/psn-pdf
April 01, 2015 - They spent 5 months training people, having joint calls, doing data
collection, and so forth before … They've learned over the last 10 years
how to get this to happen. … That seemed to dominate many safety
conversations for the last 5 or 6 years.
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - Rescue Improvement Conference Innovation Summary
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July 23, 2024
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Innovation
Contact
…
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psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - The last goal of the CMS National Quality Strategy is alignment. … Last year, we introduced two new electronic clinical quality measures (eCQMs) for glycemic control. … Sarah Mossburg: Thinking back over the last 10 years, how do you think the measurement landscape has … I think we have not changed as much as we could have or perhaps should have in the last 10 years, but … Reviewing charts is a resource-intensive and cumbersome process typically completed months after care
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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - Reviewing charts is a resource-intensive and cumbersome process typically completed months after care … The last goal of the CMS National Quality Strategy is alignment. … Last year, we introduced two new electronic clinical quality measures (eCQMs) for glycemic control. … Sarah Mossburg: Thinking back over the last 10 years, how do you think the measurement landscape has … I think we have not changed as much as we could have or perhaps should have in the last 10 years, but
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psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md
June 01, 2018 - RW : One error that we saw here a few months ago was after an emergency department ultrasound of the … It is really interesting, because we have been talking for the last decade or so about point-of-care … Fortunately, the pace has accelerated rapidly in the last few years. … the formation of the Yale Point-of-care Ultrasound Council: a multispecialty group that meets every 2 months
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psnet.ahrq.gov/node/49463/psn-pdf
October 14, 2004 - challenge hospitals, evidenced by
JCAHO making improved identification a patient safety standard in the last
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psnet.ahrq.gov/node/33876/psn-pdf
August 01, 2018 - United States has consolidated, large health care systems have
proliferated across the country in the last
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psnet.ahrq.gov/node/33659/psn-pdf
October 01, 2007 - Making Just Culture a Reality: One Organization's
Approach
October 1, 2007
Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
Perspective
We've all been there...something goes wrong,…
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psnet.ahrq.gov/node/33684/psn-pdf
May 01, 2009 - We reliably view information in a context (what was the creatinine last time?).
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.236_slideshow.ppt
March 01, 2011 - mL/hr for first 10kg
2 mL/kg/hr x 10 kg = 20 mL/hr for second 10kg
1 mL/kg/hr x 5 kg = 5 mL/hr for last
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psnet.ahrq.gov/node/33724/psn-pdf
February 01, 2012 - GYN privileges (he had completed his residency and was intending to take the boards in
the next 6 months … , "Not a
single resident has done surgery independently as the first surgeon in my program for the last
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psnet.ahrq.gov/node/33662/psn-pdf
January 01, 2008 - improvement, we saw the overall rate of those health
care–associated infections drop by 50% within 18 months … Some hospitals had moved to
such a low rate that they were actually measuring days since last infection
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psnet.ahrq.gov/perspective/disclosure-medical-error
January 01, 2009 - We made a small mistake in your care, but don't worry, you'll be fine in 6 months," is likely to have … RW: What has the research told us over the last 5 years about how patients react to disclosure, and … Those last two matter a lot to patients because they want to sense that a lesson has been learned from … The National Quality Forum issued a Safe Practice about disclosure last year.
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psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md
January 01, 2009 - RW: What has the research told us over the last 5 years about how patients react to disclosure, and … Those last two matter a lot to patients because they want to sense that a lesson has been learned from … The National Quality Forum issued a Safe Practice about disclosure last year. … We made a small mistake in your care, but don't worry, you'll be fine in 6 months," is likely to have
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psnet.ahrq.gov/node/33723/psn-pdf
December 01, 2011 - on falls in the hospital setting is probably
immaterial; at best they should be seen as an absolute last … English and Welsh hospitals: a
national observational study based on retrospective analysis of 12 months
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psnet.ahrq.gov/node/33861/psn-pdf
July 01, 2018 - RW: What have we learned in the last 5 or 10 years about trying to measure diagnostic errors? … We've just reviewed all the primary care malpractice cases for the last several years for
the two big … I immediately ordered a CT scan, but 6 months later when I saw her in the clinic and
I asked, whatever
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psnet.ahrq.gov/node/33859/psn-pdf
June 01, 2018 - RW: One error that we saw here a few months ago was after an emergency department ultrasound of the … It is really interesting, because we have been talking for the last decade or so about
point-of-care … Fortunately, the
pace has accelerated rapidly in the last few years.
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psnet.ahrq.gov/node/33789/psn-pdf
August 01, 2015 - Particularly over the last
20 or 30 years—I liken it to a Christmas tree on which we're hanging so many … If you were a quality department, you could pull the chart 3 months later and
see what the doctor wrote … Silicon Valley has figured out in the last year or two that health care is the only
part of the economy
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psnet.ahrq.gov/perspective/patient-safety-home-dialysis
April 28, 2021 - There's a lot of technology that has facilitated some of these safeguards over the last few years with
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psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
September 28, 2022 - Over the last 25 years since the IOM report “Crossing the Quality Chasm,” patient safety has been a … been times when somebody had an abnormal blood test that didn’t get reported back to the patient for months … Jones in the last week and maybe there’s an outbreak of something. … Page last reviewed November 2018. Accessed August 10, 2022. … Page last reviewed September 27, 2019. Accessed March 10, 2022.