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psnet.ahrq.gov/node/33674/psn-pdf
February 01, 2009 - These are unforeseen
consequences that pop out the back end. … NS: Let me take you back to your crystal ball, particularly to your political lens, and it's now February
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psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
November 01, 2006 - You back up and when there's an object behind you, the car beeps. … RW: Our hospital had an error with the use of a defibrillator a while back, and we found there were … Today it's quite common for physicians to turn to a book or a computer and look something up and come back … Human Factors Engineering Can Teach You How to Be Surprised Again
November 1, 2006
Perspective … References
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1. Murff HJ, Gosbee JW, Bates DW.
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psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
January 05, 2017 - It would also have the nurse and/or pharmacist conduct patient education, preferably using the "teach … back" technique.
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - , and many of these are preventable. 16 Case 2 is representative of a preventable hospital “bounce-back … inexpensive processes exist that may identify patients who were discharged prematurely and redirect them back … explain the diagnosis, condition, and next steps in the patient’s care to the patient and family and use teach … back.
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - Our first response may be automatic, but
with a little reflection, we call back, ask for additional … The Accreditation Council on Graduate Medical Education (ACGME) requires that residency programs
teach
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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/endometriosis-common-and-commonly-missed-and-delayed-diagnosis
May 26, 2021 - Looking back, from the onset of her periods, the patient felt that her physicians had implied that the … Peripheral Nerves - Leading to leg pain, abdominal muscle pain, chronic back pain, and rarely to loss … undifferentiated inflammatory conditions, neurologists for neuropathic conditions, and orthopedics for chronic back … May 7, 2014
Using the NAM diagnostic process framework to teach clinical reasoning in
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psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
September 01, 2005 - RW: From where you sit now, thinking back on how you were trained in medical school, what do you think … and Associate Chairman, Department of Medicine University of California, San Francisco
References
Back … Improving patient safety by repeating (read-back) telephone reports of critical information. … Table
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Table . … radiofrequency identification) may ultimately be required in many identification processes
Figure
Back
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psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
April 01, 2009 - Which one can we safely put on the back burner while the other high-priority project is underway? … I go back to the 1999 Institute of Medicine definition (which is also The Joint Commission definition … If you think back just 10 years ago, when hospitals were not measuring anything on any sort of national … Evidence-based Medicine: How to Practice and Teach EBM. New York, NY: Churchill Livingstone; 1997. … [go to PubMed]
Figures
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Figure 1.
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - use of verbal or telephone orders, but if used,
the order should be immediately transcribed and read back … Always request a "read-back" of the transcribed order.
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psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation
February 01, 2003 - Incidents Act," allows full access to all patient records related to adverse medical events, turning back … Anesthesiology and MedicineAssociate Dean for Patient SafetyUniversity of Miami Medical School
References
Back
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psnet.ahrq.gov/web-mm/waiting-too-long
February 01, 2013 - medical staffing requirements, which should include defined and rational protocols for primary and back-up
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - Using teach-back methods and written or online resources, ensure that patients understand why specific
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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/building-safety-program-vast-health-care-network
March 01, 2019 - in both directions—from the center to the local hospitals and clinics, and from the local entities back … The doctor came back from the second day on call and said, "I delivered 11 babies in 24 hours by myself … Then your person came back and told you that he or she delivered 11 babies, and you felt it was unsafe … We do that for premature babies, back-transfer them to a lower level nursery. … We should back-transfer people to the appropriate levels of care.
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psnet.ahrq.gov/node/33804/psn-pdf
March 03, 2016 - We were
trying to change systems back in the 1990s without labeling it as such. … That's where I got my start at CMS, back in the early 2000s. … that the providers that we're working with in quality improvement bring their data to the
table and teach … were involved in making this
work happen and facilitated it, that it provides an information stream back
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psnet.ahrq.gov/web-mm/wet-read
October 01, 2017 - prostate cancer and known bone metastases presented to the emergency department with a gradual increase in back … When radiology trainees provide preliminary reports, back-up support by attending faculty for difficult … subspecialty radiologists, perhaps “higher-risk” cases could be identified and lead to automatic attending back-up … Attending radiologists need to provide back-up for the residents, and can do so by accessing the images
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psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - Mark Chassin: Back when I was on the hospital side struggling with quality and safety problems, it
always … If you go back to the roots of The Joint Commission 100 years
ago, the goal has always been to improve … And it
goes back to the aphorism that I learned a long time ago from a very wise CIO who said, "Computers … instances of providing no-benefit health care services, like antibiotics for cold
or imaging for simple back
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psnet.ahrq.gov/web-mm/all-history
February 28, 2011 - Methods to verify received information, including repeat-back or read-back techniques. … personnel with recording demographic data and referring provider information (most importantly, a call back … Diagnoses may seem obvious initially, but time is often our best diagnostic tool, and this simple mental back-up
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - family and staff should look out for and what might happen), and Synthesis by receiver (family reads back