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Showing results for "things".

161. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety | PSNet
     psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
     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.

162. 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.

163. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37903/psn-pdf
     May 09, 2013 - history of checklists as a quality and safety tool in his book, The Checklist Manifesto: How to Get Things … perspective/conversation-withatul-gawande-md-ma-mph https://psnet.ahrq.gov/issue/checklist-manifesto-how-get-things-right

164. 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.

165. 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

166. 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.

167. 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.

168. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33748/psn-pdf
     April 01, 2013 - But once you start passing that 3- to 6-night range, things are going to get worse, and the risk of … CL: Ultimately, I think that is where things will need to go, but there are a lot of workforce and cost … I don't know that things will go that way here in the US. … We did two things in the North Carolina study. … We were also trying to understand whether things were improving over that 6-year span, particularly

169. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44483/psn-pdf
     September 09, 2015 - psnet.ahrq.gov/issue/report-morecambe-bay-investigation https://psnet.ahrq.gov/issue/openness-and-honesty-when-things-go-wrong-professional-duty-candour … https://psnet.ahrq.gov/issue/openness-and-honesty-when-things-go-wrong-professional-duty-candour

170. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? | PSNet
     psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
     September 01, 2006 - It's an interest in trying to do things the most effective way. Safety is one of those things. … , this is the Stanford way of doing things. … JB: I learned that most people were reluctant to bring things up because they would often get treated … And he asked what other things had I seen, and I pointed out a number of things that I would do differently … But we found out some other things that surprised me.

171. In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE | PSNet
     psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
     August 31, 2020 - Can you talk about how those two things interact? EL : I guess it’s a tale of two journeys.  … EL : Our publicly reported data is not perfect; we struggle with a couple of things. … We have been able to focus on some things. … and a couple of other things right now. … We may have to try five things, fifty things, before you get to the right thing for this, and then what's

172. Safety Across The Board | PSNet
     psnet.ahrq.gov/perspective/safety-across-board
     August 31, 2020 - Can you talk about how those two things interact? EL : I guess it’s a tale of two journeys.  … EL : Our publicly reported data is not perfect; we struggle with a couple of things. … We have been able to focus on some things. … and a couple of other things right now. … We may have to try five things, fifty things, before you get to the right thing for this, and then what's

173. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33742/psn-pdf
     December 01, 2012 - They were all elderly and admitted for different things, like acute myocardial infarction (MI), congestive … , there are 13 different codes that could be delirium, some of them say delirium, some of them say things … All these little things happen on the night shift because it's when things are otherwise quieter. … If you believe that many cases of delirium are caused by things that we do to patients in hospitals … I'm trying to make sure that along the way we don't do things that have unintended consequences.

174. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33764/psn-pdf
     April 01, 2014 - Is there a way to get some best practice standards out there to help people optimize these things? … I don't think that it means that we stop working on the other safety things that we've talked about, … So many things are broken, unfortunately, that trying to fix them all can be quite overwhelming. … So at least on the safety side, we're trying to have a more prominent role in making sure that things … What were the things about it that most excited you?

175. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33696/psn-pdf
     June 01, 2010 - Once I became aware of things that were going wrong, I began to look outside of medicine and to other … and distortions of their reasoning, especially in emergency medicine, which is a fertile ground for things … So when you add all those things up, you realize that to expect high-quality decision-making is somewhat … RW: Can you give us a couple of examples of things that you built into your emergency departments that … Some of them are still suffering from that secrecy and covering things up.

176. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/859646/psn-pdf
     January 04, 2024 - All these things consume materials and generate emissions. … Things that you spend more money on are typically those that have higher emissions, but it’s not one … Then, you can strategize how to mitigate those things based both on feasibility and impact, while also … Some things are difficult to clean, for example syringes and IV catheters. … Some things should remain disposable, but by and large, most things are becoming disposable these days

177. Patients' and physicians' attitudes regarding the disclosure of medical errors. | PSNet
     psnet.ahrq.gov/issue/patients-and-physicians-attitudes-regarding-disclosure-medical-errors
     March 21, 2017 - November 23, 2016 When Things Go Wrong: Voices of Patients and Families. … November 18, 2016 More than words: patients' views on apology and disclosure when things … February 16, 2011 When Things Go Wrong: Responding to Adverse Events.

178. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33760/psn-pdf
     February 01, 2014 - Probably the most important is working memory load, which is governed by many things you have to remember … If you do any of those things just ahead of the interruption task coming in, then you're fine. … All those things can work. … If you're in a clinical setting where things are particularly at risk, then there should be strict rules … We will always want to have discussions about those things. They're not going to go away.

179. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33662/psn-pdf
     January 01, 2008 - Sometimes safety improvements are generated when bad things happen to good people. … The average size of a Tenet Hospital is about 150 beds, so these things happen infrequently. … It incorporated a lot of things other than safety. … Then we built the transformation team approach, when we were going in and picking the top things that … at Tenet versus doing things at Partners.

180. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37292/psn-pdf
     May 24, 2015 - issue/many-faces-error-disclosure-common-set-elements-and-definition https://psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events … https://psnet.ahrq.gov/issue/when-things-go-wrong-voices-patients-and-families https://psnet.ahrq.gov