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Showing results for "things".

141. 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.

142. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40230/psn-pdf
     November 23, 2016 - talking-patients-and-families-about-medical-error-guide-education-and-practice https://psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events … https://psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events

143. 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

144. 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?

145. 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.

146. 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.

147. 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

148. 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.

149. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet
     psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
     September 24, 2024 - There are some things that we can keep at zero. … I think it's good for CMS to try to hold hospitals accountable for some of these things. … This is another problem with zero harm: some things can be zero, and others cannot. … And we should expect perfection in certain things.  … There are other things we do that are not predictable. I'm a primary care physician.

150. 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.

151. 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

152. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33816/psn-pdf
     October 01, 2016 - Both of those streams have matured in a way that let us do things that we only really dreamed about … There is a fairly common belief that it is easy to do these things. … It's possible to do these things where it wasn't before. … RW: Do you think that work is largely around creating standard ways of recording things? … There are very useful things for the more general field. Let's tick off some of them.

153. 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

154. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33869/psn-pdf
     November 01, 2018 - And stuff comes up in doctors' lives, they have to move and things happen. … There are some very promising trends in all of the things. … They paid the cost of hiring the doctors, research costs, and other things. … Those were all positive things from a health system perspective. … We'll see which ones stay open and turn into real things.

155. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61083/psn-pdf
     October 28, 2020 - Do you look at things like staff turnover and did that improve? … Were there any upstream things that happened that made the transfer potentially preventable? … CC: One of the simplest things we did was put hydration stations at each nursing station. … All of these things become much more labor-intensive to achieve within the nursing home. … We did learn a few things from Kansas and Chicago as they are more similar Midwestern cities.

156. First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit | PSNet
     psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
     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

157. In Conversation With… Maureen Bisognano | PSNet
     psnet.ahrq.gov/perspective/conversation-maureen-bisognano
     February 26, 2025 - RW : One of the early things you did was team up with industry to look for lessons from outside of health … It's going to call to our attention things that we may have been blinded to in the past. … RW : One of the things that it seems that you and IHI have focused on is not only telling the story of … RW : When you took over IHI from Don Berwick, you did one of the hardest things in management and in … And devastating things happened.

158. In Conversation With… J. Bryan Sexton, PhD, MA | PSNet
     psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
     February 26, 2025 - But if you're lacking in resilience it just takes little things to push people over the edge and you … When you're burned out you're not engaged, so you do things that are more expensive, you make the same … RW : You've said that it's very hard to train people on new things and innovation and get them engaged … But if you can show that by doing some little things to help them take care of themselves better, then … like new technology and a new building or some other big distracting things.

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. 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