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341. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50931/psn-pdf
     February 26, 2020 - Timely diagnosis of esophageal perforation February 26, 2020 Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation The Case  A man with mixed connective tissue disease on low-dose prednisone and methotrexate pre…

342. Spotlight
     psnet.ahrq.gov/sites/default/files/2020-05/webmm.ahrq_.gov_.392_slideshow.pptx
     January 01, 2020 - She was brought back to the emergency department and ultimately admitted to an inpatient psychiatry unit

343. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33861/psn-pdf
     July 01, 2018 - 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. … The mammogram then comes back normal, and the physician tells the patient there is nothing to worry … As she and I looked back over the record, I realized to my horror that I followed up on the abnormal

344. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. | PSNet
     psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
     July 08, 2022 - some that raise awareness and change attitudes (asking, promoting reflection, role modeling), some to teach … [Free full text] Levy MH, Adolph MD, Back A, et al. Palliative Care.

345. Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart | PSNet
     psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
     October 30, 2024 - 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

346. In Conversation With… Matthew Weinger, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
     August 01, 2018 - RW : Looking back on when you got interested in it and got involved as a faculty member, how has it played … simulation, but there's a fundamental cultural belief that's still hard to shake—the "see one, do one, teach … RW : Looking back over the last 10 to 20 years of research, how would you summarize what the research … Getting back to your prior question, in terms of other improvements, video graphics have finally started … Many educational and training units use simulation to help teach new skills, refresh old skills, and

347. Minor mistakes, deadly results. | PSNet
     psnet.ahrq.gov/issue/minor-mistakes-deadly-results
     April 02, 2008 - July 12, 2006 Discharge missteps can send seniors back to hospital.

348. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33848/psn-pdf
     December 01, 2017 - The attending back-up schedule should be appropriately staffed and accessible to everyone.

349. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49730/psn-pdf
     April 01, 2015 - Once his renal function was assessed and found to be back to baseline, his previously held antihypertensives

350. EHR Copy and Paste and Patient Safety | PSNet
     psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
     January 01, 2018 - Teach Learn Med. 2017;29:420-432. [go to PubMed] 16. Dean SM, Eickhoff JC, Bakel LA. … in the day because there were plenty of ways to cheat and game the system back then. … I don't think we were more ethical or righteous back then. … But I guess that gets back to role modeling. … Let's back off on the diuretics." This is before we've actually seen the patient.

351. In Conversation With… Susan Haas, MD, MSc | PSNet
     psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
     March 01, 2019 - We looked at this and we found so much complexity, variety, and local variation that we decided to 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.

352. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33863/psn-pdf
     August 01, 2018 - RW: Looking back on when you got interested in it and got involved as a faculty member, how has it played … simulation, but there's a fundamental cultural belief that's still hard to shake—the "see one, do one, teach … RW: Looking back over the last 10 to 20 years of research, how would you summarize what the research … simulation-based-assessment-management-critical-events-board-certified-anesthesiologists https://www.theaba.org/get-certified/ https://www.theaba.org/maintain-certification/ Getting back

353. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33828/psn-pdf
     March 01, 2017 - Folks like you have helped teach us about it. … They may hang out there for a week or more, and they will simply come back and describe what they've … Then not infrequently, we go feed it back to where we've done the observations. … It comes back to your point earlier: is there really a distinction between the people and the systems

354. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865655/psn-pdf
     April 24, 2024 - discharge, 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.

355. In Conversation With… Paul McGann, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
     July 10, 2024 - 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

356. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867653/psn-pdf
     February 26, 2025 - If that is not part of this organization, we could put that RCA back on the shelf and not look at it … Jessica Behrhorst: When we teach RCA 2, we stress that it is a toolkit, not just one tool. … I often think back to my early career. … Several years back, RCA2 got approval from The Joint Commission.

357. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49777/psn-pdf
     December 01, 2016 - She was brought back to https://psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic the … ://psnet.ahrq.gov//#references trainings, such as Mental Health First Aid, are also available and teach

358. Moving Pains | PSNet
     psnet.ahrq.gov/web-mm/moving-pains
     August 17, 2017 - min for the study and located an appropriate tank (that would allow higher-flow oxygen) for the trip back

359. In Conversation With...Donald A. Norman, PhD | PSNet
     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 Back to Top 1. Murff HJ, Gosbee JW, Bates DW.

360. In Conversation with…Carolyn Clancy, MD | PSNet
     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 Back to Top Table . … radiofrequency identification) may ultimately be required in many identification processes Figure Back