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361. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49664/psn-pdf
     January 01, 2013 - The receiving team reads back key information handed over. … consequences Situation awareness Consultants maintain overall picture and awareness by standing back

362. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/840256/psn-pdf
     November 16, 2022 - older adult is already in a skilled nursing facility, they go to the emergency department, and they go back … A care transition, from the ED or from any other healthcare setting, back to home or to another setting … Hopefully through what we do and what we provide to them, we teach them a lot of things, and you know

363. Psn-Pdf (pdf file)
     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.

364. Spotlight (pdf file)
     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.

365. In Conversation With… Sigall K. Bell, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
     February 26, 2025 - She's sitting on the exam table and her mom is there, then off to the side there's the doctor with his back … agree with, sending all those emails to your understaffed Patient Relations department and getting back … In the future, notes could even be part of the treatment, if patients could go back to read the clinician's … clinicians that we could have the visit but never look at the note again, it would be hard to come back

366. 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.

367. 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

368. Beyond the Hospital: the New Frontier of Patient Safety | PSNet
     psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
     August 01, 2014 - procedures over the course of months or even years, helping patients and physicians remember to come back … Tejal Gandhi did a paper back in 2006 about this, but the field has been very slow to gain momentum … So are they learning that today, and what strategies have you seen to try to teach that effectively? … on safety culture anymore because people were so burned out that he felt you couldn't even begin to teach

369. Making Just Culture a Reality: One Organization's Approach | PSNet
     psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
     October 01, 2007 - Page, MS, MHA Chief Safety OfficerFairview Health Services Figure Back to Top Figure. … Let's go back to hand hygiene. … That hospital needs to come back and stand behind that because they cannot tolerate a reckless group … with a letter saying that this is really important but then doesn't take action, it will drift right back … strongly toward accountability and, like most complex issues, there's a pendulum there and it tends to go back

370. Too Many Cooks in the Kitchen | PSNet
     psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
     March 07, 2018 - He was then transferred back to a surgical unit (not intensive care) with only routine vital signs and … on one possible approach while ignoring others, akin to anchoring bias. 13,14  Learning tools that teach … August 15, 2012 WebM&M Cases Back to Basics March

371. 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

372. Getting Into Patient Safety: A Personal Story | PSNet
     psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
     August 01, 2006 - None of us wanted to be part of seeing it reset to zero (perhaps some people did come back earlier to … Massachusetts General HospitalDirector, Center for Medical Simulation, Cambridge, MA References Back … Then I came back to Boston looking for work. I didn't really know what I was going to do. … Was there any sort of back story in getting that published? … Also, it seemed to me there were enough people carrying that ball that I could back away from it.

373. Empty Handoff | PSNet
     psnet.ahrq.gov/web-mm/empty-handoff
     August 01, 2017 - The receiving team reads back key information handed over. … consequences Situation awareness Consultants maintain overall picture and awareness by standing back

374. Coming Undone: Failure of Closure Device | PSNet
     psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
     April 01, 2006 - complications related to the retroperitoneal hematoma, including persistent fever, leukocytosis, ileus, and back … laboratory abnormalities that should raise suspicion of retroperitoneal bleed include hypotension, back

375. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough | PSNet
     psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
     September 01, 2003 - the OR nurse stated that there was packing in the vagina but did not ask for nor receive any repeat-back … There is active read-back/repeat-back instruction between the nurse circulator and the receiving nurse … (The primary source providers usually go back to the OR to start the next case and may not be available

376. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33866/psn-pdf
     September 01, 2018 - She's sitting on the exam table and her mom is there, then off to the side there's the doctor with his back … agree with, sending all those emails to your understaffed Patient Relations department and getting back … In the future, notes could even be part of the treatment, if patients could go back to read the clinician's … clinicians that we could have the visit but never look at the note again, it would be hard to come back

377. Artificial Intelligence and Patient Safety: Promise and Challenges | PSNet
     psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
     March 27, 2024 - AI encompasses a lot of different domains, but at the root of each of those domains is trying to teach … Let’s step back briefly and talk about the areas that AI has been used in healthcare historically. … Sarah Mossburg: I’m thinking back to the point you made earlier: that you can predict who’s at risk, … Most of our solutions don’t really consider that, so we’re back to augmenting intelligence rather than … That handoff back to humans is a fundamental concern for a lot of AI systems across industries.

378. In Conversation with...Patrick Tighe about Artificial Intelligence | PSNet
     psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
     March 27, 2024 - AI encompasses a lot of different domains, but at the root of each of those domains is trying to teach … Let’s step back briefly and talk about the areas that AI has been used in healthcare historically. … Sarah Mossburg: I’m thinking back to the point you made earlier: that you can predict who’s at risk, … Most of our solutions don’t really consider that, so we’re back to augmenting intelligence rather than … That handoff back to humans is a fundamental concern for a lot of AI systems across industries.

379. In Conversation With... Freya Spielberg, MD, MPH | PSNet
     psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
     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 if … As far back as the Heckler Report, 30 data has indicated that preventable, manageable health conditions

380. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853081/psn-pdf
     August 30, 2023 - The virtual nurse could come back and say, “Hey, did you notice the hemoglobin was this,” or “I’ve had … Instead of saying to the nurse, “I’m going to teach you how to do it,” she said to the patient, “I’m … Back when we started this, it was such a foreign concept.