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psnet.ahrq.gov/node/33863/psn-pdf
August 01, 2018 - simulation, but there's a fundamental
cultural belief that's still hard to shake—the "see one, do one, teach … For example, the FDA [Food and Drug Administration] may decide that new,
complex, and high-risk procedures … You can imagine, for example, in pediatric cardiac surgery—where you have unusual
anatomy—that the procedure … You could imagine savvy marketers of these new
technologies saying, "Your surgeon will practice the procedure … We are interested in using cognitive engineering methods to really get at
what people are thinking when
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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/perspective/evolution-patient-safety-surgery
August 01, 2017 - The attending back-up schedule should be appropriately staffed and accessible to everyone. … surgical safety and quality with rigor, blending qualitative observations pioneered by Bosk with new methods … Furthermore, emerging evidence supports the use of video recording and review of surgical procedures, … black box review after aviation crashes and near misses.( 11 )
We should also develop and implement methods … We're looking at trying to do this more broadly for many more procedures across the state of Illinois
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psnet.ahrq.gov/web-mm/all-history
February 28, 2011 - 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-withpatrick-tighe-about-artificial-intelligence
March 27, 2024 - AI encompasses a lot of different domains, but at the root of each of those domains is trying to teach … It also led us to look into different AI methods that could help with this puzzle, such as reinforcement … Another big challenge I see, especially with the more advanced methods like large language models, is … suggest looking at current strategies and practices for implementing new technologies, medications, procedures … Instead of needing to complete the EHR as they perform a procedure, with the computer between them and
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psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
March 27, 2024 - applied in healthcare, although this is rapidly changing with the advent of DL, LLMs, and other AI methods … Instead of needing to complete the EHR as they perform a procedure, with the computer between them and … AI encompasses a lot of different domains, but at the root of each of those domains is trying to teach … Another big challenge I see, especially with the more advanced methods like large language models, is … suggest looking at current strategies and practices for implementing new technologies, medications, 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/key-issues-developing-successful-hospital-safety-program
July 01, 2006 - The feedback loop needs to be closed by getting back to those who have reported incidents and unsafe … They're also going to make sure that feedback occurs, so that these actions get back to the providers … is the methodology for making changes, which includes reliable design, the rapid cycle improvement methods … from the IHI, and the other methods such as Six Sigma and Toyota Lean. … process from a physician writing an order to the delivering of a medication to a patient coming in for a procedure
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psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
July 01, 2006 - They're also going to make sure that feedback occurs, so that these actions get back to the providers … is the methodology for making changes, which includes reliable design, the rapid cycle improvement methods … from the IHI, and the other methods such as Six Sigma and Toyota Lean. … If they need to move to a higher level, the authority can move back and forth to appropriately address … process from a physician writing an order to the delivering of a medication to a patient coming in for a procedure
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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/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/role-patient-improving-patient-safety
March 01, 2007 - References
Back to Top
1. Roberg K. Kelsey's story. Am J Health Syst Pharm. 2001;58:985-987. … plight of the individual doctor or nurse who hears you and says, I need to slow down, and then goes back … You know, I can't solve the problem, but it's sad that they have to go back into this environment where … December 23, 2020
A mixed-methods analysis of patient safety incidents involving opioid
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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/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/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
January 01, 2021 - port closest to the patient, unless contraindicated or inaccessible
for use, such as during a sterile procedure … Utilize infusion sets with back-check valves and multi-port extension sets
7. … Vasoplegia after cardiovascular procedures—pathophysiology and
targeted therapy. … Errors and discrepancies in the administration of
intravenous infusions: a mixed-methods multihospital … Furniss D, Back J, Blandford A.
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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/perspective/conversation-susan-haas-md-msc
March 01, 2019 - We looked at this and we found so much complexity, variety, and local variation that we decided to back … Then your person came back and told you that he or she delivered 11 babies, and you felt it was unsafe … We do that for premature babies, back-transfer them to a lower level nursery. … We should back-transfer people to the appropriate levels of care. … It is also incumbent upon the system safety initiative to develop methods to communicate such findings
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psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
March 01, 2019 - It is also incumbent upon the system safety initiative to develop methods to communicate such findings … Then your person came back and told you that he or she delivered 11 babies, and you felt it was unsafe … We do that for premature babies, back-transfer them to a lower level nursery. … We should back-transfer people to the appropriate levels of care. … References
Related Resources From the Same Author(s)
Performing the wrong procedure
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psnet.ahrq.gov/node/60858/psn-pdf
August 26, 2020 - However, the clinician
was about to perform a high-risk procedure for another patient and no longer … medical service involves a significant number of providers, using both synchronous and
asynchronous methods … the various disciplines during discharges
from medicine units are not well understood.32 Two primary methods … patient
empowerment, caregivers should be trained in how to increase patients’ capacity for self-care.37 Teach … -
back is one method through which healthcare providers can ensure that they have explained medical
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psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
January 01, 2018 - in the day because there were plenty of ways to cheat and game the system back then. … I don't think we were more ethical or righteous back then. … But I guess that gets back to role modeling. … Let's back off on the diuretics." This is before we've actually seen the patient. … Teach Learn Med. 2017;29:420-432. [go to PubMed]
16. Dean SM, Eickhoff JC, Bakel LA.