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psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
December 18, 2024 - Nurses reinforce the risk factors, plan with the patient, and hang the tool back up each day. … If anything changes, they make adjustments and teach the patient and family. … Once people are back home, they are living their lives, and the number of risk factors expands.
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psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - There wasn't any looking back after that—I finally got a K23 grant [a larger 5-year faculty development … HS : Absolutely, and that goes back to the time that I was in practice.
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psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
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
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psnet.ahrq.gov/node/73334/psn-pdf
August 01, 2024 - Back-check
valves, which prevent backflow of medication due to differences in pressure in an IV infusion … Utilize infusion sets with back-check valves and multi-port extension sets
7. … Furniss D, Back J, Blandford A.
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psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
March 27, 2024 - On day 3 after the first ED visit, the child was brought back to the ED by ambulance with pulseless electrical … December 9, 2020
Using an online quiz-based reinforcement system to teach healthcare
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - Closed-loop communication , voicing back instructions and receiving confirmation, is recommended to assure
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psnet.ahrq.gov/node/33732/psn-pdf
July 01, 2012 - How did your time in
Washington inform your day job now when you got back to Harvard?
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - SPOTLIGHT CASE
Failure to Report
Citation Text:
Spath P. Failure to Report. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
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psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
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/perspective/building-capacity-patient-safety
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/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - in the clinic or hospital with an acute condition that could be treated episodically, sending them back … RW : Yes, but I could see it as moving back to the primary issue about teams versus hierarchy, if that's … research shows that TeamSTEPPS works, it is much harder to change behaviors that are established than to teach
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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - research shows that TeamSTEPPS works, it is much harder to change behaviors that are established than to teach … in the clinic or hospital with an acute condition that could be treated episodically, sending them back … RW : Yes, but I could see it as moving back to the primary issue about teams versus hierarchy, if that's
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psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - Upon thorough review, the respiratory distress was traced back to an inadvertent injection of vecuronium
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
January 31, 2024 - Recognition of the multifactorial contributors to diagnostic safety spans back almost 20 years with Dr
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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - Back-check valves, which prevent backflow of medication due to differences in pressure in an IV infusion … standardized fashion Administer high-alert medications as primary infusions Utilize infusion sets with back-check … Furniss D, Back J, Blandford A.
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psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - We did our first cultural survey back in 1998 to set the benchmark. … The data were then fed back to each VISN and facility. … Health PolicyHarvard School of Public HealthStaff Physician, VA Boston Healthcare System
References
Back
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psnet.ahrq.gov/node/50754/psn-pdf
December 18, 2019 - The Case
A 63-year-old woman with a history of liver transplantation secondary to hepatitis C, low back
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psnet.ahrq.gov/node/848107/psn-pdf
April 26, 2023 - Recognition of the multifactorial contributors to diagnostic safety spans back almost 20 years with
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psnet.ahrq.gov/node/33750/psn-pdf
May 01, 2013 - AJ: Two things that have really held us back on progress on patient safety: one is incentives, which
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psnet.ahrq.gov/node/49681/psn-pdf
April 01, 2013 - a different dose or units than the original order, then the process should stop for
clarification back