-
psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - On postoperative day 15, she called back again with ongoing nausea. … One approach would have been to ask open-ended questions, utilize the teach-back method or ‘repeat what … consider assessing the patient’s learning style and incorporating understanding checks through the teach-back … questions, active listening, interpretation of body language, assessment of patient learning style, and teach-back … methods.
-
psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
November 01, 2006 - Would you have called this an "expected complication" of the procedure and moved on? … References
Back to Top
1. Murff HJ, Gosbee JW, Bates DW. … Cognitive and usability engineering methods for the evaluation of clinical information systems. … You back up and when there's an object behind you, the car beeps. … While you have those people in, you might rewrite some of the procedures.
-
psnet.ahrq.gov/node/49417/psn-pdf
October 01, 2003 - The test
result (positive, with a viral load of 32,000 copies/mL) came back more than 1 week after the … Such approaches involve three areas: clear delineation of roles and
responsibilities, better methods … For example, workers in commercial aviation and the military read-back key
transmissions and use standard … verbal handoffs more seriously than
hospitals: you are more likely to hear "let me read your order back … Resident satisfaction on an academic
hospitalist service: time to teach.
-
psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - The test result (positive, with a viral load of 32,000 copies/mL) came back more than 1 week after the … Such approaches involve three areas: clear delineation of roles and responsibilities, better methods … For example, workers in commercial aviation and the military read-back key transmissions and use standard … verbal handoffs more seriously than hospitals: you are more likely to hear "let me read your order back … Resident satisfaction on an academic hospitalist service: time to teach.
-
psnet.ahrq.gov/issue/beyond-find-and-fix-improving-quality-and-safety-through-resilient-healthcare-systems
August 04, 2021 - Citation Text:
Anderson JE, Ross AJ, Back J, et al. … Twitter
Linkedin
Copy URL
April 15, 2020
Anderson JE, Ross AJ, Back … Using ethnographic methods and resilient healthcare principles (described as systems that anticipate … URL
Cite
Citation
Citation Text:
Anderson JE, Ross AJ, Back … January 30, 2013
Society of Interventional Radiology IR Pre-Procedure Patient Safety
-
psnet.ahrq.gov/node/33692/psn-pdf
February 01, 2010 - We'd like to teach residents how to, for instance, use practice-based learning and
improvement tools … Looking back now 5 years later, how do you think that's gone? … duty hour restrictions may not have changed all that much, other than the natural
evolution of the procedures … There, the issue is more continuity of experience in the acute illness phase rather
than an issue of procedure … requirements based on empiric observation as opposed to professional
opinion, which is our current method
-
psnet.ahrq.gov/issue/buried-answers
May 11, 2005 - The author interviews experts who discuss the autopsy as a unique method for discovering medical mistakes … September 12, 2016
Bring back the autopsy.
-
psnet.ahrq.gov/issue/waiting-urgent-procedures-weekend-among-emergently-hospitalized-patients
September 04, 2019 - Study
Waiting for urgent procedures on the weekend among emergently hospitalized … Waiting for urgent procedures on the weekend among emergently hospitalized patients. … Waiting for urgent procedures on the weekend among emergently hospitalized patients. … Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods … December 23, 2008
Improving patient safety by repeating (read-back) telephone reports
-
psnet.ahrq.gov/node/33707/psn-pdf
February 01, 2011 - address this need, a few programs have been
developed for practicing physicians and other caregivers to teach … The purpose was to encourage sharing and collaboration of QI methods across the system and to
further … University of Texas System
References
https://psnet.ahrq.gov//#table
https://psnet.ahrq.gov//#ref14
Back … Teach health care
professionals about QI
4. Research & develop
new knowledge for QI
5. … training, 2)
Institutional and
peer
recognition, and
3) Financial
reward for
achieving
objectives
Back
-
psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
December 20, 2023 - an insulin pen and vial contain the same active ingredient, they differ in terms of the delivery method … were categorized as critically impactful , defined as rationing, delaying, or canceling treatments or procedures … rationing criteria (85%), changing order sets or protocols (75%), delaying or canceling treatments or procedures … Assessing the patient/caregiver’s ability to administer the medication and using the teach-back method … When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures
-
psnet.ahrq.gov/node/49519/psn-pdf
September 01, 2006 - He also complained of new left-sided back pain. … Meanwhile, the patient continued to feel well except for mild back pain. … Many of these errors are caught before harm reaches the patient, as practitioners have a variety of
methods … diagnosis, updated medications and problem list, current baseline
status (eg, cardiac status), and recent procedures … Improving patient safety by
repeating (read-back) telephone reports of critical information.
-
psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
February 01, 2010 - Participating EIP programs have developed methods to conduct individual practice assessment in ambulatory … We'd like to teach residents how to, for instance, use practice-based learning and improvement tools … duty hour restrictions may not have changed all that much, other than the natural evolution of the procedures … There, the issue is more continuity of experience in the acute illness phase rather than an issue of procedure … requirements based on empiric observation as opposed to professional opinion, which is our current method
-
psnet.ahrq.gov/web-mm/triple-handoff
March 01, 2004 - He also complained of new left-sided back pain. … Meanwhile, the patient continued to feel well except for mild back pain. … Many of these errors are caught before harm reaches the patient, as practitioners have a variety of methods … diagnosis, updated medications and problem list, current baseline status (eg, cardiac status), and recent procedures … The receiver of signout should "repeat-back" or "read-back" the information in the tasks, thus allowing
-
psnet.ahrq.gov/node/853772/psn-pdf
September 27, 2023 - if an insulin pen and vial contain
the same active ingredient, they differ in terms of the delivery method … were categorized
as critically impactful, defined as rationing, delaying, or canceling treatments or procedures … rationing criteria (85%), changing order sets or protocols (75%), delaying or canceling
treatments or procedures … Assessing the patient/caregiver’s ability to administer the medication and using the teach-back
method
-
psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
February 01, 2010 - We'd like to teach residents how to, for instance, use practice-based learning and improvement tools … duty hour restrictions may not have changed all that much, other than the natural evolution of the procedures … There, the issue is more continuity of experience in the acute illness phase rather than an issue of procedure … requirements based on empiric observation as opposed to professional opinion, which is our current method … Participating EIP programs have developed methods to conduct individual practice assessment in ambulatory
-
psnet.ahrq.gov/node/33740/psn-pdf
November 01, 2012 - I
would be the first to say that the routine annual physical, for example, is a low-yield procedure. … When we have our training sessions, we call them the "Stanford
Medicine 25" sessions, we teach people … But, it's clearly not a one-way street where we are showing them only old-
fashioned methods. … I'd never go back. … I think the pendulum is swinging back.
-
psnet.ahrq.gov/issue/patient-safety-case-based-comprehensive-guide
March 05, 2014 - January 13, 2016
Why Things Bite Back: Technology and the Revenge of Unintended Consequences … April 12, 2006
Patient Safety Culture: Theory, Methods and Application. … February 10, 2010
Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive. … February 10, 2016
Bring back the autopsy. … January 20, 2020
Formative evaluation of the video reflexive ethnography method, as applied
-
psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
September 01, 2007 - My method of tapping the M&M conference's full potential is called the "M+M Matrix"a patient safety … Future work should aim to measure the satisfaction of participants and the impact of this method on safety … Table
Back to Top
Table. … What methods do you use to identify those structures? … Now I'm writing from the perspective of a teacher, having to teach on people so that there will be people
-
psnet.ahrq.gov/issue/closing-loop-guide-safer-ambulatory-referrals-ehr-era
July 12, 2017 - providers, clear standards of accountability for patient follow-up, and use of evidence-based communication methods … like teach-back with patients and families.
-
psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
September 01, 2007 - Now I'm writing from the perspective of a teacher, having to teach on people so that there will be people … My method of tapping the M&M conference's full potential is called the "M+M Matrix"a patient safety … Future work should aim to measure the satisfaction of participants and the impact of this method on safety … Table
Back to Top
Table. … What methods do you use to identify those structures?