-
psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
May 01, 2007 - That's where we can go back to the lessons of the airline industry. … Systematic data collection of the hazards of health care can be traced back at least to the time of Florence … Charles Vincent, PhD Professor of Clinical Safety Research, Imperial College London
References
Back
-
psnet.ahrq.gov/perspective/evolution-root-cause-analysis
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, RCA 2 got approval from The Joint Commission.
-
psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
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, RCA 2 got approval from The Joint Commission.
-
psnet.ahrq.gov/node/866055/psn-pdf
May 29, 2024 - To sustain
the gains from this campaign, Ascension is launching a “We Got Your Back” cultural campaign
-
psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
February 28, 2024 - Then building data systems to be able to monitor those risks and ultimately to develop tools to push back
-
psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
September 01, 2011 - The VA has done a very good job with getting back to the reporter. … In fact, not only do they get back about acknowledging and personally thanking them for doing the report … part, so people get demoralized after a year or two: "I keep filling out these reports, I never hear back … not only in terms of listening and doing, creating a meaningful action plan to fix things but getting back … The actions that hospital leaders take in response to reports teach providers whether the time and risks
-
psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - The actions that hospital leaders take in response to reports teach providers whether the time and risks … The VA has done a very good job with getting back to the reporter. … In fact, not only do they get back about acknowledging and personally thanking them for doing the report … part, so people get demoralized after a year or two: "I keep filling out these reports, I never hear back … not only in terms of listening and doing, creating a meaningful action plan to fix things but getting back
-
psnet.ahrq.gov/periodic-issue/periodic-issue-404
August 30, 2023 - weight loss, constipation for several days, subjective fevers at home, and mild pain in the chest, back
-
psnet.ahrq.gov/perspective/adverse-events-dentistry
December 22, 2020 - KH : Let’s go back to the “BigMouth” data repository. … They have the electronic health record that is more than just front and back systems for patient demographics … KH : Going back to our discussion about specific adverse events, we had talked about infection control
-
psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-walji-phd
December 22, 2020 - KH : Let’s go back to the “BigMouth” data repository. … They have the electronic health record that is more than just front and back systems for patient demographics … KH : Going back to our discussion about specific adverse events, we had talked about infection control
-
psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - empowerment, caregivers should be trained in how to increase patients’ capacity for self-care. 37 Teach-back
-
psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - Treatment with insulin will cause a potassium shift back to the intracellular volume and can trigger
-
psnet.ahrq.gov/web-mm/weighing-surgical-safety
August 04, 2021 - However, most morbidly obese patients also have back and knee osteoarthritis, which severely limits physical
-
psnet.ahrq.gov/node/60865/psn-pdf
August 31, 2020 - KH: Let’s go back to a couple of points you have made that I’d like to highlight.
-
psnet.ahrq.gov/node/60721/psn-pdf
July 21, 2020 - right now because they’ve got the survivor attitude and
they're just waiting for all of this to go back … level of business being conducted via telehealth will continue, or are you hoping
to get most people back … We hope that after this is all over we're going to go back to something more structured. … I don’t think we’re ever going to go back to the model of care we were in before, so we better be thinking
-
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
-
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.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
-
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?
-
psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd
November 01, 2018 - With that back-of-the-envelope calculation, I guessed you could handle around 200 patients. … RW : Do you use any artificial intelligence–based algorithm or is the back of that same envelope to figure … Every week she would get up and repeat back the comments, which named the individual doctors by name.
-
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.