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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
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psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma
March 01, 2011 - overlapping shifts, standardization of content, minimal interruptions, structured language, and read back—things … Very few people are using read back even though it's been suggested. … unstable and the handoff is more than just temporary in the sense that the team may or may not be coming back … sign-out with their cross cover who's going to be covering that patient for 8 to 12 hours until they come back … Effectiveness of a course designed to teach handoffs to medical students.
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psnet.ahrq.gov/web-mm/discharged-blindly
October 26, 2022 - At a minimum, the clinicians should have asked the patient to verbally repeat (“teach back”) their instructions
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psnet.ahrq.gov/web-mm/slippery-slide-life
January 21, 2017 - 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/primer/health-literacy
September 07, 2019 - Confirming comprehension : Use a teach-back or show me method .
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psnet.ahrq.gov/node/849660/psn-pdf
May 31, 2023 - to engage
patients as active partners in their healthcare, (6) Confirming comprehension using the teach-back
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.17_slideshow.ppt
June 01, 2003 - Transition of care points are high risk for propagation
To minimize this type of error, take a step back
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psnet.ahrq.gov/perspective/conversation-chris-cebollero-bs-ccemt-p
May 26, 2021 - job when we see EMTs [emergency medical technicians] and paramedics in the workforce and we have to teach … How do we teach this younger generation? … KH: I'd like to get back to error reporting because I think that's something that's consistent across … be able to figure out the “why” when you’re looking at errors in clinical care to ensure that we can teach … Are trauma registries or any registries that may interface with EMS used for looking back at care?
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psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
January 07, 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/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - 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 to … rapidly, the right atrial appendage should be re-cannulated emergently so the patient can be placed 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/node/838221/psn-pdf
September 28, 2022 - As an
educator, I've developed a new curriculum, Community-Oriented Quality Improvement, to teach medical … worker was able to go to grandma's house, get the meds, bring them to the patient,
and get the patient back … Some states are going back
to the requirement that telemedicine is done with video, and this will result … The
community health workers can teach them how to do that, collect the information on their vitals
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psnet.ahrq.gov/node/33699/psn-pdf
August 01, 2010 - MDProfessor of Medicine Vice Dean for Academic AffairsTulane University School of
Medicine
References
Back … Med Teach.
2005;27:298-3016. [go to PubMed]
24. Walton MM, Shaw T, Barnet S, Ross J. … [go to
PubMed]
Figure
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Figure.
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psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - Patient summary, Action list, Situational awareness and contingency planning, and Synthesis or read-back
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psnet.ahrq.gov/web-mm/inadvertent-castration
October 27, 2010 - Mandatory team briefings, with invitations by the team leader for participants to step back and speak
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psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
February 28, 2024 - explanation of the value of the TeamSTEPPS curriculum, and guidance for instructors or trainers who teach … The website has resources , including training slides, for people who teach TeamSTEPPS.
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psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
February 28, 2024 - The website has resources , including training slides, for people who teach TeamSTEPPS. … explanation of the value of the TeamSTEPPS curriculum, and guidance for instructors or trainers who teach
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psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-registered-nurses-perspective
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/perspective/balancing-supervision-and-autonomy-ongoing-tension
February 01, 2012 - recognized and addressed.( 15 )
Rather than our profession's previous mantra of "see one, do one, teach … RW : In getting that right, is that a matter of training our faculty to pull back and to ask those questions … I find it's the fellows who begin to push back if they don't get given the cases. … We have to take a step back and say, "How do we not thwart all the advances we've made in patient safety
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psnet.ahrq.gov/node/841468/psn-pdf
December 14, 2022 - This surgeon recommended taking the patient back to
the operating room so that her tongue laceration
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psnet.ahrq.gov/node/33822/psn-pdf
January 01, 2017 - PO: I have to go back in my career a little bit. … I have a long-standing engagement with health and medical
care going back to the 1960s. … PO: When I was at Alcoa, I created the Alcoa University and offered to teach people in the community … So you're no longer taking care of four patients; you're sitting on your butt waiting for your
back … One
thing you have to do is beat back the legal staff who don't want you to tell anybody that there