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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 … they were able to
find issues and to catch potential problems, such as labs, medication errors, or procedures … 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. … It’s an internal technology, consisting of a monitor on
the wall, camera, and method of calling.
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - Emerging Handoff Curricula Although numerous curricula and instructional methods have been developed … outcomes remains elusive due to a lack of handoff-specific patient outcomes.( 5 ) A common way to teach … necessary to evaluate receivers on use of active listening behaviors, such as interactive questioning, read-back … July 19, 2019
Patient safety room of horrors: a novel method to assess medical students … physician remote access of the electronic health record and implications for resident supervision: a mixed methods
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psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
April 01, 2009 - Does this distinction have any relevance to the role of accreditation, regulation, and other methods … Deciding on the minimum level of quality, the best programs and procedures to be used to achieve it, … Evidence-based Medicine: How to Practice and Teach EBM. New York, NY: Churchill Livingstone; 1997. … [go to PubMed]
Figures
Back to Top
Figure 1. … The analytic methods we have are from a different generation.
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - learned that, rather than just fixing things for our practice or the guy down the hall,
with the right methods … A patient lost their hand in a
farm accident and we put it back on and it's working again, and aren't … If I, as CEO, can look them in the eye and say, the board is expecting us to
come back in 3 months with … delays because you have to send it out to
get all the data from whoever has to vet the stuff and get it back
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psnet.ahrq.gov/web-mm/miscalculated-risk
March 01, 2015 - The Case A healthy 36-year-old man was admitted to a teaching hospital for acute low back strain after … 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 … Equianalgesic conversion methods are easily used, but the results are estimates.
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psnet.ahrq.gov/node/49579/psn-pdf
March 21, 2009 - Methods to verify received information, including repeat-back or read-back techniques. … personnel with recording demographic data and referring provider information (most
importantly, a call back … Diagnoses may seem obvious initially, but time is often our best diagnostic tool, and
this simple mental back-up
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psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
November 01, 2006 - While you have those people in, you might rewrite some of the procedures. … Human Factors Engineering Can Teach You How to Be Surprised Again
November 1, 2006
Perspective … Would you have called this an "expected complication" of the procedure and moved on? … References
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1. Murff HJ, Gosbee JW, Bates DW. … Cognitive and usability engineering methods for the evaluation of clinical information systems.
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psnet.ahrq.gov/node/33674/psn-pdf
February 01, 2009 - of the 1000 physicians or 5000 nurses to each do the right
thing every time is probably the weakest method … These are unforeseen
consequences that pop out the back end. … NS: Let me take you back to your crystal ball, particularly to your political lens, and it's now February
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psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
April 04, 2018 - Case & Commentary—Part 1 A 42-year-old man with a history of asthma and chronic lower back pain was … been 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/issue/healthcare-411-special-report-national-patient-safety-awareness-week
October 18, 2006 - April 21, 2005
10-State project to study methods to reduce central line-associated bloodstream … November 30, 2011
Don't come back, hospitals say.
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psnet.ahrq.gov/periodic-issue/periodic-issue-399
July 31, 2023 - Clinicians and caregivers both stated that teach-back protocols were helpful but inconsistently used. … A prospective, mixed methods study in primary care. … The most frequent never events were wrong site or wrong patient surgery, wrong surgical procedure, and … weight loss, constipation for several days, subjective fevers at home, and mild pain in the chest, back … , the order was not communicated verbally and he was allowed to eat, leading to postponement of the procedure
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psnet.ahrq.gov/node/33834/psn-pdf
May 22, 2017 - ,
are also increasingly popular, although there is limited evidence regarding whether or how these methods … such as abuse-deterrent formulations to improve
safe use, dispensing, and storage of opioids; take-back
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psnet.ahrq.gov/node/33876/psn-pdf
August 01, 2018 - It is also
incumbent upon the system safety initiative to develop methods to communicate such findings … in both
directions—from the center to the local hospitals and clinics, and from the local entities back
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psnet.ahrq.gov/issue/measuring-quality
June 21, 2017 - June 10, 2020
A method to identify pediatric high-risk diagnoses missed in the emergency … May 8, 2024
Adverse events in long-term care residents transitioning from hospital back … March 30, 2022
A mixed methods evaluation of medication reconciliation in the primary … August 19, 2015
Patient safety room of horrors: a novel method to assess medical students … April 24, 2019
Risk factors and outcomes for foreign body left during a procedure: analysis
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psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
May 22, 2017 - Let's say that I had a 55-year-old guy with chronic low back pain. … to you, once the taper has been effective, that the fog seems to have lifted and their old self is back … A typical story is somebody who started opioids for a bad hip or back. … If we were to step back and speak about what the overarching goals of drug therapy are, it's almost too … tools, are also increasingly popular, although there is limited evidence regarding whether or how these methods
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - tools, are also increasingly popular, although there is limited evidence regarding whether or how these methods … such as abuse-deterrent formulations to improve safe use, dispensing, and storage of opioids; take-back … Let's say that I had a 55-year-old guy with chronic low back pain. … A typical story is somebody who started opioids for a bad hip or back. … If we were to step back and speak about what the overarching goals of drug therapy are, it's almost too
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
April 01, 2013 - nutrition (PN)
Describe the PN-use process
Identify potential PN-related medication errors
Describe methods … http://www.ncbi.nlm.nih.gov/pubmed/22301325
*
Other Errors with PN
Depending on preparation method … or have different dose or units than original order, then the process should stop for clarification back … order
*
*
Take-Home Points
PN is a high-alert medication requiring safety-focused policies, procedures
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psnet.ahrq.gov/node/49664/psn-pdf
January 01, 2013 - work involves making tradeoffs, for example, between safety and
efficiency or risk and reward; that procedures … The receiving team reads back key information handed over. … We found that our method—which involves a clear process division between handoff
preparation, equipment … consequences
Situation
awareness
Consultants maintain overall
picture and awareness by
standing back
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - conditions from blood use within expected norms and incidental lysis of adhesions (both relatively trivial procedures … References
Back to Top
1. Zhan C, Miller MR. … HCUP Methods Series Report No. 2006-01. … of the 1000 physicians or 5000 nurses to each do the right thing every time is probably the weakest method … These are unforeseen consequences that pop out the back end.
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psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
October 01, 2008 - of the 1000 physicians or 5000 nurses to each do the right thing every time is probably the weakest method … These are unforeseen consequences that pop out the back end. … conditions from blood use within expected norms and incidental lysis of adhesions (both relatively trivial procedures … References
Back to Top
1. Zhan C, Miller MR. … HCUP Methods Series Report No. 2006-01.