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psnet.ahrq.gov/node/854897/psn-pdf
October 31, 2023 - Failed double checks have been traced back to trust in colleagues,
distractions or interruptions, and
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psnet.ahrq.gov/node/49513/psn-pdf
July 01, 2006 - min for the study and located an appropriate tank (that would allow higher-flow
oxygen) for the trip back
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psnet.ahrq.gov/node/50615/psn-pdf
October 30, 2019 - Concerns about accurate identification and the “unintended” consequences of Doe use stretch back to the
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psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
May 22, 2017 - Let's say that I had a 55-year-old guy with chronic low back pain. … to you, once the taper has been effective, that the fog seems to have lifted and their old self is back … A typical story is somebody who started opioids for a bad hip or back. … If we were to step back and speak about what the overarching goals of drug therapy are, it's almost too … We need to step back and always deal with the patient in front of us and ask ourselves what makes sense
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - such as abuse-deterrent formulations to improve safe use, dispensing, and storage of opioids; take-back … Let's say that I had a 55-year-old guy with chronic low back pain. … A typical story is somebody who started opioids for a bad hip or back. … If we were to step back and speak about what the overarching goals of drug therapy are, it's almost too … We need to step back and always deal with the patient in front of us and ask ourselves what makes sense
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psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
August 01, 2010 - Then you move on to part two, which is watching a video that we created back in Pittsburgh called "The … Professor 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
Back to Top
Figure.
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - As an educator, I've developed a new curriculum, Community-Oriented Quality Improvement, to teach medical … The community health workers can teach them how to do that, collect the information on their vitals if … back to the patient. … Then, we equally need to demand from those organizations that they share information back with us in … a timely manner and make sure those patients understand as they come back, that there is a transition
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psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd
February 01, 2014 - You can get back into the task. … They teach us a lot about the sorts of systems we can eventually put in place to minimize distraction … that the person using your system might be distracted, turn away to do something else, and then come back … Of course the person answered the text message and went back and forgot to order the medicine and it
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - "( 2 ) Shortly after the Physician Charter was written, Hafferty and Castellani, harkening back to Aristotle
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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - Failed double checks have been traced back to trust in colleagues, distractions or interruptions, and
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psnet.ahrq.gov/node/60172/psn-pdf
March 01, 2021 - This individual attended staff meetings to explain the purpose of the program and to
teach frontline … new process has become the accepted way of doing business, with
few if any staff considering going back
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psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - I had noticed, even before
I discovered that article, that many patients were coming back to the hospital … CMS
came back to us after we successfully launched publicly reported mortality measures in heart failure … If readmissions drop, then savings accrue, and patients—who are generally not eager
to come back to … Patients were coming back to the hospital for a
range of problems often not directly related to why … One time I came back from an overseas trip.
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psnet.ahrq.gov/node/33752/psn-pdf
August 01, 2013 - Sometimes where you start is to get
people back to their fighting strength so that they can work on … (It used to be called Bouncing Back from Burnout, but that had a negative ring to it.) … RW: As we think back on the early years of the quality and safety movement, let's say, 8 or 10 years … The concept of simplifying work is very appealing and it clearly links back to what we need to do for … I'll go back to that hallway interaction with that nurse as something
that really changed the course
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psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
February 26, 2025 - message, the pager would go off, and the risk manager would listen to it and could call the physician back … Then you throw a mistake on top of that, and it feels like the straw breaking the camel's back. … way of approaching the problem when you went to law school, or was it after you finished and you came back … thought were horrible, it would be 3–6 months before the trial date, and defense attorneys would come back
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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - some that raise awareness and change attitudes (asking, promoting
reflection, role modeling), some to teach … Levy MH, Adolph MD, Back A, et al. Palliative Care.
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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - that raise awareness and
change attitudes (asking, promoting reflection, role modeling),
some to teach … Levy MH, Adolph MD, Back A, et al. Palliative Care. J Natl Compr Canc Netw. 2012;10(10):1284-1309.
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psnet.ahrq.gov/node/33724/psn-pdf
February 01, 2012 - 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/perspective/what-does-simulation-add-teamwork-training
October 01, 2004 - Anesthesiologist; Director, Patient Simulation Center of InnovationVA Palo Alto Health Care System
References
Back … Box
Back to Top
Inexpensive Simulation? … Table
Back to Top Table.
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psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - RW : As you look back, why didn't diagnosis get the attention it deserved for the first 10 years of the … Sometimes I won't hear about a patient that I missed with back pain that ended up at another hospital … Especially a patient who you may have misdiagnosed who is angry and upset or didn't come back. … As she and I looked back over the record, I realized to my horror that I followed up on the abnormal … Perhaps the patient should have called me, as I encourage them to do if I don't get back to them on key
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psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
February 26, 2025 - Sometimes where you start is to get people back to their fighting strength so that they can work on process … (It used to be called Bouncing Back from Burnout, but that had a negative ring to it.) … RW : As we think back on the early years of the quality and safety movement, let's say, 8 or 10 years … The concept of simplifying work is very appealing and it clearly links back to what we need to do for … I'll go back to that hallway interaction with that nurse as something that really changed the course