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Showing results for "things".

141. In Conversation With… Gordon Schiff, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
     February 26, 2025 - We tried to create a taxonomy looking at the types of things that could go wrong in the diagnostic process … RW : You've named a lot of exciting things. … You've talked about things that facilitate communication between generalists and specialists. … There are all sorts of things, but they don't come out of the box from the EHR that any of us can buy … All those things conspired to have an error that I felt very badly about.

142. In Conversation With… Mary Dixon-Woods, DPhil | PSNet
     psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
     March 01, 2017 - As you came into health care, what were the surprising things you saw about the way physician culture … They can use it to say things that otherwise are forms of what we call forbidden knowledge. … I'm sick of things that work once. … And there is this sense that it's in that category of things like communication skills and other things … People are inclined to think, "They're the kind of things that we're doing anyway.

143. Identifying Adverse Events Not Present on Admission: Can We Do It? | PSNet
     psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
     October 01, 2008 - But I think that there will be some element of systemization of these kinds of things. … bloodstream infections, these seven things to prevent falls, and these nine things to prevent decubitus … Many of the things that people talk about as safety issues in fact are. … The policy pipeline has been pretty thoughtful about what things we should do. … , and if they did them religiously, that would prevent 90% of these bad things from happening.

144. Workplace Safety in Health Care | PSNet
     psnet.ahrq.gov/perspective/workplace-safety-health-care
     January 01, 2017 - were generally not very good at other things. … To do it, we must have more agreement on how we do things. … PO : Again, several things. I need to be careful here not to overgeneralize. … what you do by learning from things gone wrong. … So these things go together.

145. In Conversation With… Paul H. O'Neill, MPA | PSNet
     psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
     January 01, 2017 - were generally not very good at other things. … To do it, we must have more agreement on how we do things. … PO : Again, several things. I need to be careful here not to overgeneralize. … what you do by learning from things gone wrong. … So these things go together.

146. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33754/psn-pdf
     September 01, 2013 - But, essentially, the Newtonian laws of how these things move through the air have been figured out … We need to examine a couple of things when we make those claims. … We have systems thinking on the one hand: If you want to understand why things go wrong you've got to … To say these are humans, things happen in our systems that are so complex, resource constrained, and … related to, for example, the coloring of the soap versus the disinfectant, all kinds of things that

147. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33706/psn-pdf
     February 01, 2011 - That means I didn't forget things, and then the big one—if things went south—I knew where everything … BJ: We got interested in that from a couple of different things. … We did other things that were really important. … But we have a real collaborative now running of people who teach these things broadly. … What's your theory for change or how you move things?

148. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60173/psn-pdf
     March 30, 2020 - BS: That’s hard to answer because there were a lot of little things. … BS: Since the last report, one of the things that has matured the most on the technology front is the … There are things that are really powerful in there like simulation, and clinical decision support. … BS: I’d say two things. … BS: It’s also interesting to think about some things that may go away because they do work rather than

149. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45525/psn-pdf
     November 18, 2016 - //psnet.ahrq.gov/issue/support-medical-apology-nonlegal-arguments https://psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events … health-implications-apologizing-after-adverse-event https://psnet.ahrq.gov/issue/more-words-patients-views-apology-and-disclosure-when-things-go-wrong-cancer-care

150. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33736/psn-pdf
     September 01, 2012 - Jack Needleman: Two things about nurse staffing issues intrigue me. … In the normal course of things, that would imply we need more nurses, not fewer nurses. … Think about your to-do list as a stack of things to get done. … There's some evidence that patients have been made safer, but all other things are not equal. … JN: A couple of things are going on.

151. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety | PSNet
     psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
     March 01, 2017 - They can use it to say things that otherwise are forms of what we call forbidden knowledge. … RW : As I listen to you, I'm wondering how you can prevent all of the bad things from happening. … I'm sick of things that work once. … And there is this sense that it's in that category of things like communication skills and other things … People are inclined to think, "They're the kind of things that we're doing anyway.

152. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33712/psn-pdf
     June 01, 2011 - His book Why Things Bite Back: Technology and the Revenge of Unintended Consequences is a seminal work … RW: Checklists are a very hot issue in health care, the idea that things that we've relied on human memory … established procedures and bend them if in their culture they feel this is really necessary to get things … Many of these things can be foreseen. … them complained about senior management or suggested to me that they were denied the ability to get things

153. In Conversation With… Neel Shah, MD, MPP | PSNet
     psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp
     October 30, 2019 - Only a woman in labor can tell you how much energy she has to push; she can tell you things that nobody … NS: So many things about childbirth are justifiably exceptional. … RW: Maybe because of all of that rolled together, you're expecting things will go well, and it strikes … Similarly, in other parts of the world where things are much worse, people just normalize how things … It lives in the brain of the mom, who can tell you things that nobody else can, like how much energy

154. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33789/psn-pdf
     August 01, 2015 - you the number of root cause analyses where someone said, "If we just had computers, it would make things … But when you do turn it on, it doesn't make things better, and you don't see the productivity gains … Like many things in medical errors and safety, it's hard to categorize. … Patients or their families now can do things for themselves through new digital tools. … Because I get to do all those things and they cross-fertilize one another.

155. The PeaceHealth Governance Journey in Support of Quality and Safety | PSNet
     psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
     August 01, 2007 - I kept saying somebody ought to fix these things. And it turns out, "somebody" was me. … I eventually worked my way up from fixing things in my little hallway to fixing things for the whole … methods I could fix things for 100, then 300 doctors. … They don't get in and fix things, obviously. That's not their job. … , not things like the average time to answer a call light on the fifth floor.

156. In Conversation with...James L. Reinertsen, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
     August 01, 2007 - I kept saying somebody ought to fix these things. And it turns out, "somebody" was me. … I eventually worked my way up from fixing things in my little hallway to fixing things for the whole … methods I could fix things for 100, then 300 doctors. … They don't get in and fix things, obviously. That's not their job. … , not things like the average time to answer a call light on the fifth floor.

157. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47835/psn-pdf
     April 24, 2019 - issue/digital-doctor-hope-hype-and-harm-dawn-medicines-computer-age https://psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences … https://psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences https

158. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33879/psn-pdf
     May 01, 2019 - Things that have worked are forcing a "time out," where they verify the patient's name and ID, the procedure … about being in the back of a van weaving in and out of traffic at 70 miles an hour that make those things … generally the right call to go to the place with more capacity or to go to the local place and get things … RW: Are they doing things in the field where you worry about whether they have the wherewithal and the … I'm thinking about thrombolysis, and you see more and more things being pushed into the ambulance because

159. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853081/psn-pdf
     August 30, 2023 - If you’re on the night shift, you can call up your nurse preceptor and talk things through. … That’s one of the things that we use virtual nursing for that is a little bit different, and that’s … The other thing is when they do patient education, they can go over things on the big screen. … Those are all things that we’re looking at in this vision for the future—what virtual nursing could … So many things could be tied together.

160. In Conversation with... Charles Ornstein | PSNet
     psnet.ahrq.gov/perspective/conversation-charles-ornstein
     October 01, 2009 - facilities and how things can go wrong. … All these types of things should be on the radar screen and monitored regularly. … There's nothing like a call from a reporter to get things moving. … Sometimes bad systems allow for bad people to do bad things. … And helping to explain those things together.