Results

Total Results: 108 records

Showing results for "never sometimes usually always".

41. In Conversation With… Erik Hollnagel, PhD | PSNet
    psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
    February 26, 2025 - With IT—when the developer promises the earth and never delivers, it just makes it even more complicated … Patient Safety Committee and we hear about cases, it strikes me that to change anything now almost always … In fact, sometimes there are contradictory regulations. … called efficiency–thoroughness trade-off or ETTO , which means that people in everyday work situations usually … They all do it with the best of intentions, but sometimes they should reflect a little more on their

42. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet
    psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
    March 25, 2020 - gurney, the OR team noticed that the electrocardiogram cable that enables synchronized cardioversion was never … Patients with significant aortic stenosis usually develop left ventricular hypertrophy, which makes the … There is never any guarantee that shocking the ventricle will terminate VF. … There should never be any delay with cardioversion or defibrillation because staff cannot find the defibrillator … However, VF can sometimes be refractory to defibrillation.

43. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33728/psn-pdf
    May 01, 2012 - One of the reasons may be that we focused on a lot of errors that never impact a patient. … Some never impact a patient and some can dramatically impact a patient. … occurred in the Medicare study—more than a quarter of the patients had them and minor events were sometimes … So we'll always have a human review to assess and validate its accuracy. … DC: The feedback loop is usually that air traffic controller having access to the patient information

44. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
    January 01, 2024 - , the OR team noticed that the electrocardiogram cable that enables synchronized cardioversion was never … heart from beating during bypass. 12 Background (5) • Patients with significant aortic stenosis usually … • There is never any guarantee that shocking the ventricle will terminate VF. … • There should never be any delay with cardioversion or defibrillation because staff cannot find … • However, VF can sometimes be refractory to defibrillation.

45. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73302/psn-pdf
    May 26, 2021 - CC: I think a lot of the organizations, especially the ones that I've worked [with], always set up the … Sometimes it's an entry-level job when we see EMTs [emergency medical technicians] and paramedics in … Your first call is always your field supervisor. … KH: Do you have the equivalent of “never events” in the hospital that automatically trigger more scrutiny … CC: Usually the trauma registries are really just to determine the amount of trauma and what's being

46. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/865429/psn-pdf
    April 24, 2024 - , the OR team noticed that the electrocardiogram cable that enables synchronized cardioversion was never … Patients with significant aortic stenosis usually develop left ventricular hypertrophy, which makes the … There is never any guarantee that shocking the ventricle will terminate VF. … However, VF can sometimes be refractory to defibrillation. … Cardiac OR staff should always be prepared to put their patient back on bypass urgently if VF or other

47. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/836879/psn-pdf
    April 27, 2022 - medical news in 30- to 60-second sound bites (except in the midst of a pandemic), and the content usually … Sometimes people believe that they're the victim of an error when they weren't, and sometimes, they … So you can't always just go by the testimony of an individual. … Professionalism alone won't do it, and has never done it, as physician leaders in this field have openly … The media: an essential, if sometimes arbitrary, promoter of patient safety.

48. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33826/psn-pdf
    February 01, 2017 - many people—working alone and together—need to use judgment to respond to new situations that they've never … In health care, it's usually even more the case. … Sometimes people in CEO roles are physicians or nurses; sometimes they're not. … It's always been remarkable to me, compared with other or business organizations how hospitals have … three coexisting, but sometimes not even coacting, hierarchies all trying to run the same place.

49. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? | PSNet
    psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
    September 01, 2006 - By allowing each VISN (and usually each facility) to decide how it should meet its performance targets … My father used to always tease me about it. … Sometimes I was successful in interceding with the professors, explaining that's not really how to use … Well, I always say that the person who thinks it can never happen to them is the most dangerous person … Whereas, in the private sector, that isn't always the case.

50. In Conversation with…Pat Croskerry, MD, PhD | PSNet
    psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
    June 01, 2010 - In the emergency department, you usually don't know the patient, you don't necessarily have access to … And you can watch them happen: You can just stand back sometimes and admire the cognitive choreography … She's always here. It never amounts to anything; she's just a frequent flyer." … Some work has been done on this, but if you feel very positively toward the patient, sometimes there … There's always a huge residue of uncertainty that we must learn to live with.

51. In Conversation With… David Blumenthal, MD, MPP | PSNet
    psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
    July 01, 2012 - I've always tried to keep that in mind. … And its never been done in the history of human affairs for health information. No models exist. … Doing so requires that we are aware when we err, and sometimes this is not easy to do. … For example, while surgical errors are usually obvious, the vast majority—probably more than 95%—of medication … Also, sometimes when physicians order exactly the right medication, dose, schedule, and route for the

52. Patient Safety and Health Information Technology: Learning from Our Mistakes | PSNet
    psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
    July 01, 2012 - Doing so requires that we are aware when we err, and sometimes this is not easy to do. … For example, while surgical errors are usually obvious, the vast majority—probably more than 95%—of medication … Also, sometimes when physicians order exactly the right medication, dose, schedule, and route for the … I've always tried to keep that in mind. … And its never been done in the history of human affairs for health information. No models exist.

53. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33820/psn-pdf
    December 01, 2016 - Now we could argue that's what root cause analysis wants to do, but it doesn't always work out that … Usually there are many. … Even in the rare situation that they do look at them, they virtually never have an explicit, transparent … Sometimes the public or the press may be unsophisticated, and instead of having the attention span to … So it's not like this is just a theoretical construct that's never been employed with reasonable success

54. In Conversation With… Amy C. Edmondson, PhD, AM | PSNet
    psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
    February 01, 2017 - many people—working alone and together—need to use judgment to respond to new situations that they've never … In health care, it's usually even more the case. … Sometimes people in CEO roles are physicians or nurses; sometimes they're not. … It's always been remarkable to me, compared with other or business organizations how hospitals have three … Globally, this uptake is harder to estimate; we are always amazed when we receive a call from Europe,

55. New Insights About Team Training From a Decade of TeamSTEPPS | PSNet
    psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
    February 01, 2017 - In the context of teamwork, fidelity of the simulation is usually less important than how the simulation … Globally, this uptake is harder to estimate; we are always amazed when we receive a call from Europe, … many people—working alone and together—need to use judgment to respond to new situations that they've never … In health care, it's usually even more the case. … Sometimes people in CEO roles are physicians or nurses; sometimes they're not.

56. Lost in the Black Hole | PSNet
    psnet.ahrq.gov/web-mm/lost-black-hole
    December 01, 2005 - The hospitalist never received the new report and, lacking a reminder system, forgot to follow up on … The quantitative PCR test for HIV viral load, however, is usually used to monitor response to therapy … Although computerization of information transfer is part of the answer, verbal handoffs will always occur … 1, 2017 Perspective The Media: An Essential, If Sometimes

57. In Conversation with...Mark Chassin, MD, MPP, MPH | PSNet
    psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
    April 01, 2009 - There aren't usually even two or three. … Quality and safety are sometimes used interchangeably in health care, but they too should be distinguished … It is impossible for all care to be above average; there will always be a distribution of quality. … very complex system, and it is difficult and dangerous to assume that well-intentioned changes will always … practicing medicine today, I know that he would support efforts to improve quality and safety, because he always

58. In Conversation with...Joseph Britto, MD | PSNet
    psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
    February 01, 2007 - questions arise in almost every clinical encounter—and sadly, two out of these three remain unanswered, sometimes … Diagnosis decision support systems will never replace good, conscientious clinicians at the bedside. … heuristics known to affect subconscious processing, such as advice to offset the availability heuristic by always … The patient is usually right. I bet her ulcer is back! She should have stayed on that omeprazole. … The patient is usually right. I bet her ulcer is back! She should have stayed on that omeprazole.

59. What Do We Know About Emergency Department Safety? | PSNet
    psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
    June 01, 2010 - In the emergency department, you usually don't know the patient, you don't necessarily have access to … And you can watch them happen: You can just stand back sometimes and admire the cognitive choreography … She's always here. It never amounts to anything; she's just a frequent flyer." … Some work has been done on this, but if you feel very positively toward the patient, sometimes there … There's always a huge residue of uncertainty that we must learn to live with.

60. In Conversation with... Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS | PSNet
    psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
    December 14, 2022 - conceptual overview of work and understand processes at a high, representational level, work-as-imagined never … Sometimes I think of these concepts as different lenses of a multifaceted gem, where you turn the gem … Sometimes people are using resilient practices in clinical care settings, but they are not necessarily … in taking care of a simulated patient in their real clinical settings with real equipment, there is usually … I think there is one more component that is not always articulated.