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psnet.ahrq.gov/node/33634/psn-pdf
May 04, 2006 - Leape, MDAdjunct Professor of Health PolicyHarvard School of Public Health
References
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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
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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
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psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - He was discharged back to a chronic care facility.
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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
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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
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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/perspective/making-just-culture-reality-one-organizations-approach
October 01, 2007 - Page, MS, MHA Chief Safety OfficerFairview Health Services
Figure
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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.
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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.
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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