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psnet.ahrq.gov/issue/against-silence-development-and-first-results-patient-survey-assess-experiences-safety
March 24, 2021 - April 7, 2010
Systematic review of medication safety assessment methods. … August 4, 2010
Medication double-checking procedures in clinical practice: a cross-sectional … treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back … October 23, 2013
Strengths and weaknesses of working with the Global Trigger Tool method
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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/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - 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-karl-bilimoria-md-ms-0
December 01, 2017 - ; they score each other so they get a score sheet with comments and standardized scores about their procedure … We're looking at trying to do this more broadly for many more procedures across the state of Illinois … 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,
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psnet.ahrq.gov/perspective/workplace-safety-health-care
January 01, 2017 - For some GYN procedures requiring lithotomy, the nurse must remove the bed end. … Job Safety Analysis of GYN Procedure. … PO : I have to go back in my career a little bit. … PO : When I was at Alcoa, I created the Alcoa University and offered to teach people in the community … Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience
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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/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/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/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/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/periodic-issue/periodic-issue-423
January 04, 2024 - Regulatory bodies, health systems, and researchers are continuously investigating methods to ensure safe … This article describes the development of a mixed methods toolkit (including a behavior observation tool … Book/Report
Retained Swabs Following Invasive Procedures: Themes Identified from … The family was called back to the PED for further evaluation and a parent disclosed that the child had … No fracture or foreign body was identified on x-ray but the procedure note did not mention whether the
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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/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/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/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/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/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/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/issue/next-patient-safety
September 11, 2019 - October 27, 2021
Looking back on the history of patient safety: an opportunity to reflect … November 4, 2020
Medication safety in mental health hospitals: a mixed-methods analysis
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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