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psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - conflicting reports, the ED physician returned to the EMR and noted that this mistaken
history of PE dated back … Investigating further back, the ED physician discovered that the letters "PE" were first noted nearly … The Commentary
Copying of notes in the medical record is a practice that dates back at least 100 years … Education and mentoring
There is a dearth of effective strategies to teach and foster high-quality and … In reflecting back to our case presentation, it does end on an upbeat note with the emergency physician
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psnet.ahrq.gov/node/33657/psn-pdf
September 01, 2007 - folklore is easily detectable; the moderator needs to be willing and able to steer the
conversation back … Reference
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1. Wachter RM, Shojania KG. … Table
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Table. Example Questions(Go to table citation in perspective)
Question #1? … (Matrix Conference of 7/7/05)
Slide Presentation
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An Overview of the M+M Matrix Program
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psnet.ahrq.gov/issue/impact-pharmacist-facilitated-hospital-discharge-program-quasi-experimental-study
December 21, 2014 - Study
Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.
Citation Text:
Walker PC, Bernstein SJ, Jones JNT, et al. Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study. Arch Intern Med. 2009;169(21):2003-10. d…
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psnet.ahrq.gov/issue/responding-clinicians-who-fail-follow-patient-safety-practices-perceptions-physicians-nurses
February 24, 2011 - Study
Responding to clinicians who fail to follow patient safety practices: perceptions of physicians, nurses, trainees, and patients.
Citation Text:
Driver TH, Katz PP, Trupin L, et al. Responding to clinicians who fail to follow patient safety practices: perceptions of physicians, nu…
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psnet.ahrq.gov/node/49725/psn-pdf
January 01, 2015 - The surgery was proceeding uneventfully when the surgeon requested that
the PA catheter be pulled back … to speed up the transfer process, the attending anesthesiologist refloated the PA catheter himself
back … incorporating the following components: identify–situation–observations–background–agreed plan–read
back
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psnet.ahrq.gov/node/33643/psn-pdf
December 01, 2006 - RW: How do you relate this back to a policy level?
BS: Keep it evidence based, period.
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Patient summary, Action list, Situational
awareness and contingency planning, and Synthesis or read-back
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psnet.ahrq.gov/node/865429/psn-pdf
April 24, 2024 - Unintended mechanical overdistension of the atria when blood is re-infused from the
bypass machine back … For this reason, the clinicians in this case were trying to rapidly cardiovert the patient back to
sinus … As soon as electrocautery is no longer needed, the setting on the
pacing box should be changed back … in VF, the team would have had to re-cannulate the right atrium, re-heparinize the patient and go
back … Cardiac OR staff should always be prepared to put their patient back on bypass urgently if VF or
other
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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 - Unintended mechanical overdistension of the atria when blood is re-infused from the
bypass machine back … • For this reason, the clinicians in this case were trying to rapidly cardiovert the
patient back … – As soon as electrocautery is no longer needed, the setting on the pacing box should
be changed back … restored rapidly, the right atrial appendage
should be re-cannulated so the patient can be placed back … in VF, the team would have had to re-cannulate the right
atrium, re-heparinize the patient and go back
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psnet.ahrq.gov/issue/patient-safety-case-based-comprehensive-guide
March 05, 2014 - January 13, 2016
Why Things Bite Back: Technology and the Revenge of Unintended Consequences … February 10, 2010
Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive. … February 10, 2016
Bring back the autopsy.
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psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
April 01, 2018 - I had noticed, even before I discovered that article, that many patients were coming back to the hospital … If readmissions drop, then savings accrue, and patients—who are generally not eager to come back to the … One time I came back from an overseas trip. … literacy, using language appropriate to patient understanding, utilizing visuals, and practicing the teach-back … Is "teach-back" associated with knowledge retention and hospital readmission in hospitalized heart failure
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psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - literacy, using language appropriate to patient understanding, utilizing visuals, and practicing the teach-back … Is "teach-back" associated with knowledge retention and hospital readmission in hospitalized heart failure … If readmissions drop, then savings accrue, and patients—who are generally not eager to come back to the … One time I came back from an overseas trip. … We now know that people end up back in the hospital quite frequently, and some of the ways the system
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psnet.ahrq.gov/node/73906/psn-pdf
October 06, 2021 - emergency and
what’s normal and who to ask if she's not sure, and that she feels like she’d want to come back … stay, she might go home and have a headache and have high blood pressure and say, “Well
I’m not going back … devices], and
to be provided instructions for their follow-up care, and then we see that they can't fall back … nursery, but not if you had a C-section [cesarean section] and you're trying to hoist
your baby out and back … to do with this hypertension curriculum idea is to build the
model for what it looks like to really teach
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psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc
June 01, 2016 - As you reflect back over 15 or 20 years of experience, has anything surprised you in terms of content … GM : I often reflect back on the honor and privilege I had to be there at the beginning of the federal … A few years ago for the series, I called him back to do an update on safety culture . … When I think back to my days at AHRQ, we had a fantasy that something like this would begin to happen … If I had to think back on a few major changes that I tried to make in health care organizations that
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psnet.ahrq.gov/issue/missed-diagnoses-acute-myocardial-infarction-emergency-department-variation-patient-and
April 08, 2018 - treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back
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psnet.ahrq.gov/node/33705/psn-pdf
January 01, 2011 - , CRICO/RMF
Kathy Dwyer Program Director, Loss Prevention and Patient SafetyCRICO/RMF
References
Back … [go to PubMed]
Table
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Table.
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psnet.ahrq.gov/node/49497/psn-pdf
December 01, 2005 - responsibility for independent practice, a model sometimes derisively referred to as “see one, do one, teach … away from
traditional lecture-based techniques and embrace new modalities in order to effectively teach … language used in the delivery room often is not standardized, important
communications are rarely read back
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psnet.ahrq.gov/web-mm/sloppy-and-paste
February 02, 2011 - conflicting reports, the ED physician returned to the EMR and noted that this mistaken history of PE dated back … Investigating further back, the ED physician discovered that the letters "PE" were first noted nearly … The Commentary
Copying of notes in the medical record is a practice that dates back at least 100 years … Education and mentoring
There is a dearth of effective strategies to teach and foster high-quality … In reflecting back to our case presentation, it does end on an upbeat note with the emergency physician
-
psnet.ahrq.gov/perspective/conversation-charles-ornstein
October 01, 2009 - But if you try to lie about it, it will come back to you. … So, going back to King/Drew Medical Center, one of the things that we thought was really important was … Tom Garthwaite, who is the former head of the Los Angeles County health system, said was that you can teach … right thing is, you can make sure that they have the skills, but the bottom line is you cannot always teach … Table
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Table.
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - Looking back at the big, mediagenic errors over the past 25 years ( Table ), a striking pattern emerges … Table
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Table. … But if you try to lie about it, it will come back to you. … Tom Garthwaite, who is the former head of the Los Angeles County health system, said was that you can teach … right thing is, you can make sure that they have the skills, but the bottom line is you cannot always teach