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221. Key Issues in Developing a Successful Hospital Safety Program | PSNet
     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

222. Spotlight (pdf file)
     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.

223. Building a Safety Program in a Vast Health Care Network | PSNet
     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

224. Psn-Pdf (pdf file)
     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.

225. Artificial Intelligence and Patient Safety: Promise and Challenges | PSNet
     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

226. In Conversation with...Patrick Tighe about Artificial Intelligence | PSNet
     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

227. Suicidal Ideation in the Family Medicine Clinic | PSNet
     psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
     October 01, 2007 - She was brought back to the emergency department and ultimately admitted to an inpatient psychiatry unit … a supportive manner.( 8 ) Longer 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

228. In Conversation With… Robert Hirschtick, MD | PSNet
     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.

229. Psn-Pdf (pdf file)
     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.

230. Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions | PSNet
     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.

231. In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD | PSNet
     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.

232. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety | PSNet
     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

233. Total Parenteral Nutrition, Multifarious Errors | PSNet
     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

234. Getting Into Patient Safety: A Personal Story | PSNet
     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

235. In Conversation With…David C. Classen, MD, MS | PSNet
     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

236. EHR Copy and Paste and Patient Safety | PSNet
     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.

237. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head | PSNet
     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

238. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866055/psn-pdf
     May 29, 2024 - Elements include verification and resolution of incorrect counts; a brief summary of the procedure and … Visual counter uses a white board that includes the patient identifiers and procedure details. … After they determined a simple plan for providers to follow in highly complex procedures, they knew … 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.

239. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49531/psn-pdf
     March 01, 2007 - answer, although the mistake would most likely be attributed to an unexplainable lapse in following procedures … To prevent unintentional unsafe acts—slips, lapses, mistakes, or procedure violations—the contributory … Make it easy to report and provide several different reporting methods.

240. Psn-Pdf (pdf file)
     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.