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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33634/psn-pdf
    May 04, 2006 - Leape, MDAdjunct Professor of Health PolicyHarvard School of Public Health References Back to Top
  2. psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
    August 01, 2006 - the biggest problem was that the economists had taken over, and it was time for the doctors to get 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. … None of us wanted to be part of seeing it reset to zero (perhaps some people did come back earlier to
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49427/psn-pdf
    January 01, 2004 - Mandatory team briefings, with invitations by the team leader for participants to step back and speak
  4. psnet.ahrq.gov/web-mm/medication-overdose
    September 01, 2011 - He was discharged back to a chronic care facility.
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33619/psn-pdf
    September 01, 2005 - RW: From where you sit now, thinking back on how you were trained in medical school, what do you think
  6. psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
    August 22, 2014 - 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 … procedures over the course of months or even years, helping patients and physicians remember to come back
  7. 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 teachback.
  8. 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
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851870/psn-pdf
    July 31, 2023 - The Patient Safety Authority will take that information and get it back to the healthcare facilities … throughout Pennsylvania in terms of workforce education and getting safety event and risk information back
  10. psnet.ahrq.gov/issue/next-patient-safety
    September 11, 2019 - October 27, 2021 Looking back on the history of patient safety: an opportunity to reflect
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846125/psn-pdf
    March 15, 2023 - It was critical that frontline staff could communicate concerns they were seeing with patients back
  12. psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
    January 01, 2020 - Details • Patient was hypertensive in the post-anesthesia care unit (PACU) and then transferred back
  13. 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
  14. 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
  15. psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
    April 01, 2009 - ProfessorSchool of Public Administration University of Victoria Victoria, BC, Canada References Back … Evidence-based Medicine: How to Practice and Teach EBM. New York, NY: Churchill Livingstone; 1997. … [go to PubMed] Figures Back to Top Figure 1. … 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
  16. psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
    February 12, 2020 - In the ED, the patient complained of pain in her epigastric region and back.
  17. 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
  18. 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.
  19. 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.
  20. psnet.ahrq.gov/web-mm/transition-nowhere
    March 21, 2009 - Once his renal function was assessed and found to be back to baseline, his previously held antihypertensives

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