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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - To sustain the gains from this campaign, Ascension is launching a “We Got Your Back” cultural campaign … Auditors review at least 20 operating room procedures per month. … Elements include verification and resolution of incorrect counts; a brief summary of the procedure and … To sustain the gains from this campaign, Ascension is launching a “We Got Your Back” cultural campaign … Auditors review at least 20 operating room procedures per month.
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psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - 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/emergence-trigger-tool-premier-measurement-strategy-patient-safety
May 01, 2012 - We published an article in JAMA back in the 1990s, where we were able to review on a daily basis all … RW : How about the specificity of those different methods? … RW : Should the other methods of error detection go away? … demonstrated very good test characteristics of finding adverse events, and then people instinctively push back … When we do, then I think we may come back to the article I mentioned from LDS Hospital where 70% of
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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/perspective/conversation-withdavid-c-classen-md-ms
May 01, 2012 - We published an article in JAMA back in the 1990s, where we were able to review on a daily basis all … RW : How about the specificity of those different methods? … RW : Should the other methods of error detection go away? … demonstrated very good test characteristics of finding adverse events, and then people instinctively push back … When we do, then I think we may come back to the article I mentioned from LDS Hospital where 70% of
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psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
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. … HFE interventions commonly focus on people, tools, technology, procedures, and processes.
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psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
November 16, 2022 - HFE interventions commonly focus on people, tools, technology, procedures, and processes. … 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.
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - But of course to deliver on the value of all those discoveries, the pieces have to come back together … That comes back to the basic premise of the research I've been doing over many years, which is that some … You can swing it back into the health care setting. … Workarounds are nonstandard methods for accomplishing work blocked by dysfunctional processes.( 7 , 8 … Finally, some individuals develop workarounds that are superior to existing procedures.
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psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
August 01, 2009 - Workarounds are nonstandard methods for accomplishing work blocked by dysfunctional processes.( 7 , 8 … Finally, some individuals develop workarounds that are superior to existing procedures. … Lumry Family Assistant Professor of Business Administration Harvard Business School
References
Back … But of course to deliver on the value of all those discoveries, the pieces have to come back together … You can swing it back into the health care setting.
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psnet.ahrq.gov/node/49681/psn-pdf
April 01, 2013 - Describe methods to reduce PN-related errors. … the PN.(5) Error
rates for preparing complex admixtures (including PN) are 22% to 37% depending on method … In addition to optimizing the ACD, standard operating procedures
should be in place to independently … a different dose or units than the original order, then the process should stop for
clarification back … Take-Home Points
PN is a high-alert medication requiring safety-focused policies, procedures, and systems
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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - Before performing the procedure, the clinician contacted the pharmacy with instructions to proceed with … medical service involves a significant number of providers, using both synchronous and asynchronous methods … various disciplines during discharges from medicine units are not well understood. 32 Two primary methods … 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 information
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psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
January 01, 2018 - Teach Learn Med. 2017;29:420-432. [go to PubMed]
16. Dean SM, Eickhoff JC, Bakel LA. … 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.
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psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
August 01, 2006 - minor events that are harbingers of bigger problems); others through the thoughtful adoption of new procedures … (for instance, checkout of equipment before procedures, protocols for handoffs during relief of one … Was there any sort of back story in getting that published? … March 29, 2023
Insurance claims for wrong-side, wrong-organ, wrong-procedure, or … June 15, 2011
Using a multi-method, user centred, prospective hazard analysis to assess
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psnet.ahrq.gov/node/49777/psn-pdf
December 01, 2016 - She was brought back to
https://psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
the … ://psnet.ahrq.gov//#references
trainings, such as Mental Health First Aid, are also available and teach … Another best practice is counseling patients specifically on lethal means, methods for suicide with high
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psnet.ahrq.gov/node/861880/psn-pdf
January 31, 2024 - family and staff should look out for and what might happen),
and Synthesis by receiver (family reads back … contextual determinants to high
adherence to structured family-centered rounds: a national multi-site mixed methods … A conceptual
framework informed by scoping and narrative literature review methods.
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psnet.ahrq.gov/node/73334/psn-pdf
August 01, 2024 - based units.37
Conversion to a single method of dosing (e.g., weight-based dosing) can be implemented … 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. … Furniss D, Back J, Blandford A.
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - Describe methods to reduce PN-related errors. … the PN.( 5 ) Error rates for preparing complex admixtures (including PN) are 22% to 37% depending on method … In addition to optimizing the ACD, standard operating procedures should be in place to independently … have a different dose or units than the original order, then the process should stop for clarification back … Take-Home Points PN is a high-alert medication requiring safety-focused policies, procedures, and
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psnet.ahrq.gov/node/33649/psn-pdf
May 01, 2007 - 1950s and 1960s, it had all been about technical
factors: the design of aircraft, the development of procedures … structure, and what seems to be invariable across national boundaries,
organizational systems, and payment methods … That's where we can go back to the lessons of the
airline industry.
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psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
March 27, 2024 - CME activity which has been mitigated through UC Davis Health, Office of Continuing Medical Education procedures … over-the-counter ibuprofen, as well as some forgetfulness and concentration difficulties as he tried going back … However, about two weeks later, the patient’s wife insisted that he go back to the hospital for worsening … , clinical work satisfaction, and patient care coordination between primary care providers: a mixed methods … September 18, 2019
A mixed methods study examining teamwork shared mental models of interprofessional