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psnet.ahrq.gov/issue/economic-evaluation-healthcare-safety-which-attributes-safety-do-healthcare-professionals
July 01, 2012 - April 22, 2009
Improving patient safety by repeating (read-back) telephone reports of … May 3, 2023
Defining avoidable healthcare-associated harm in prisons: a mixed-method
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - "( 2 ) Shortly after the Physician Charter was written, Hafferty and Castellani, harkening back to Aristotle … 14, 2014
A dynamic risk management approach for reducing harm from invasive bedside procedures … September 22, 2021
Perspective
Aviation Safety Methods:
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson
February 01, 2013 - answer all your questions or for you to share all your observations at that time, someone can come back … RW : As we try to engage patients in new ways and also teach them a new set of skills, is technology … BJ : I think we need to use a variety of methods designed to reach patients and families more effectively … If we can get back to the mindset that we're in a partnership together, we make decisions together, we
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psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - RW : As you look back, why didn't diagnosis get the attention it deserved for the first 10 years of the … Sometimes I won't hear about a patient that I missed with back pain that ended up at another hospital … Especially a patient who you may have misdiagnosed who is angry and upset or didn't come back. … Maybe you would only hear about it from a malpractice lawsuit—not the best method for learning. … I was trying to rely on my memory or yellow post-its, but those are unreliable methods.
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psnet.ahrq.gov/node/49517/psn-pdf
August 01, 2006 - miscalculated-risk
The Case
A healthy 36-year-old man was admitted to a teaching hospital for acute low back … It is
important to note that other analgesic conversion methods are available and that equianalgesic … doses may
differ depending on which conversion method is used.(8,9) In addition, equianalgesic dose … ensure that prescribers, nurses, and pharmacists are all comfortable with
equianalgesic calculation methods … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
Equianalgesic conversion methods
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - transitions or reporting and follow-up of laboratory and other diagnostic tests; unnecessary tests or procedures … toxic cascades” of unnecessary tests, reducing exposure to unnecessary risk of harm from unnecessary procedures … As an educator, I've developed a new curriculum, Community-Oriented Quality Improvement, to teach medical … The community health workers can teach them how to do that, collect the information on their vitals if … back to the patient.
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psnet.ahrq.gov/node/857260/psn-pdf
November 30, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP
(Stop SGLT2 Inhibitor Three days bef-O-re Procedures … Lab Value (normal range) Pre-Procedure Day of Procedure Day After Procedure Readmission (day after discharge … Day of Procedure Day After Procedure Readmission (day after discharge)
Glucose (74-109mg/dL) 123 133 … His pre-procedure medication instructions were to stop all medications the night prior to the procedure … Using teach-back methods and written or online resources, ensure that patients
understand why specific
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psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
April 01, 2009 - The analytic methods we have are from a different generation. … We certainly see examples—fortunately they are uncommon—of physicians undertaking procedures that they … Does this distinction have any relevance to the role of accreditation, regulation, and other methods … Evidence-based Medicine: How to Practice and Teach EBM. New York, NY: Churchill Livingstone; 1997. … [go to PubMed]
Figures
Back to Top
Figure 1.
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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 … carry forward these methods in their own. … I really love seeing that people that we work
with are carrying forward those methods.
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psnet.ahrq.gov/periodic-issue/periodic-issue-425
February 28, 2024 - This review identified alternative investigative methods such as Safety II and inclusion of the patient … Event rates ranged from 0.34 events per 1,000 patient days (CDI-HO) to 0.87 events per 1,000 procedures … trial provided either standard discharge medication instructions or an intervention which included teach-back … This review identified alternative investigative methods such as Safety II and inclusion of the patient … During the procedure, his expired tidal volume decreased from 560 ml to about 330 ml.
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psnet.ahrq.gov/node/33861/psn-pdf
July 01, 2018 - RW: As you look back, why didn't diagnosis get the attention it deserved for the first 10 years of the … Sometimes I won't hear about a patient that I missed with
back pain that ended up at another hospital … Especially a patient who you
may have misdiagnosed who is angry and upset or didn't come back. … Maybe you would only hear about it
from a malpractice lawsuit—not the best method for learning. … I was trying to rely on my memory or yellow post-its, but those are unreliable methods.
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
June 14, 2023 - But I want to make sure that people understand it’s that back and forth. … It’s not a good way to teach. … Another partnership opportunity at the organizational level, which was set back by the pandemic, is having … It is essential to teach and share information about medications for the transition of going home. … the functioning of PFACs in some hospitals; however, many hospital staff quickly adapted to virtual methods
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psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - the functioning of PFACs in some hospitals; however, many hospital staff quickly adapted to virtual methods … But I want to make sure that people understand it’s that back and forth. … It’s not a good way to teach. … Another partnership opportunity at the organizational level, which was set back by the pandemic, is having … It is essential to teach and share information about medications for the transition of going home.
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psnet.ahrq.gov/node/49690/psn-pdf
September 01, 2013 - Case & Commentary—Part 1
A 42-year-old man with a history of asthma and chronic lower back pain was … prescribing high doses of long-acting morphine (MS Contin), oxycodone, and gabapentin for his low back … The patient in this case was prescribed opioids for his low back pain. … Providers should ensure full informed consent before prescribing opioids and determine methods to
monitor … Opioids for back pain patients: primary care prescribing patterns
and use of services.
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psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
February 01, 2013 - answer all your questions or for you to share all your observations at that time, someone can come back … RW : As we try to engage patients in new ways and also teach them a new set of skills, is technology … BJ : I think we need to use a variety of methods designed to reach patients and families more effectively … If we can get back to the mindset that we're in a partnership together, we make decisions together, we
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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 … 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 … transitions or reporting and follow-up of laboratory and other diagnostic tests; unnecessary tests or procedures … toxic cascades” of unnecessary tests, reducing exposure to unnecessary risk of harm from unnecessary procedures
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - Case #2:
A patient underwent an anterior/posterior urogynecologic procedure. … 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 … Using a standardized method to identify patients with vaginal packing.
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psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd
February 01, 2014 - You can get back into the task. … They teach us a lot about the sorts of systems we can eventually put in place to minimize distraction … that the person using your system might be distracted, turn away to do something else, and then come back … Of course the person answered the text message and went back and forgot to order the medicine and it … Methods Inf Med. 2011;50:447-453. [go to PubMed]
2. Relihan E, O'Brien V, O'Hara S, Silke B.
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psnet.ahrq.gov/issue/fatigue-and-risk-are-train-drivers-safer-doctors
September 03, 2016 - August 29, 2012
Patient Safety Culture: Theory, Methods and Application. … Enhancing patient safety during hand-offs: standardized communication and teamwork using the 'SBAR' method … October 19, 2016
Transgender patients and diagnostic safety: back to basics.
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psnet.ahrq.gov/issue/good-medical-care-can-suffer-late-day
December 16, 2020 - May 19, 2021
Looking back on the history of patient safety: an opportunity to reflect … A prospective, mixed methods study in primary care. … safety incidents for people with intellectual disabilities in NHS acute hospitals: evidence from a mixed-methods … May 1, 2019
Clinical reasoning assessment methods: a scoping review and practical guidance