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psnet.ahrq.gov/node/33708/psn-pdf
March 01, 2011 - VA: In the handoff community, we're starting to standardize the way we talk about these things; we use … Well, certainly admission, which includes things like
transfer from EMS [emergency medical services] … So you really sense that it's a very dynamic process, and things could go wrong at any step. … The challenge is that more things are being handed off now of course with duty hours. … an EKG, placing an arterial line, things that are very susceptible to
sleep loss.
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psnet.ahrq.gov/node/33826/psn-pdf
February 01, 2017 - One way to look at what's happening in that scenario is that the leader's
mental model of how things … Today's leaders need to stop and challenge themselves when things go wrong. … And, it's great,
because when things go wrong, they can say, "It's not my fault." … There was no apparent standardization, even around
things that could be standardized. … How does that movement relate
to the things we've been talking about?
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psnet.ahrq.gov/node/33700/psn-pdf
October 01, 2010 - And nobody can
either read or do 80 things. … PP: I wish I could tell you that I was more scholarly in choosing those things. … One of the things we're working on now is being more quantitative in how you reduce guidelines to a … for things that we're never
going to measure as rates. … And we don't have the kind of rigorous investment
that we need to really make things happen.
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psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph
December 21, 2022 - Most of my early work had to do with things that were explicitly regulatory in nature, and I was also … The interesting thing about that study , like a lot of other things in quality of health care, was that … And that was the appropriate metaphor in which to view these things. … The physicians report that they are not doing things they used to.
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psnet.ahrq.gov/node/33849/psn-pdf
January 01, 2018 - So all of these good things have happened. … If someone wanted to commit fraud in the paper-and-pen day, you had to write those
things by hand. … Then I start at the top and delete and add and modify things. That's a time saver for me. … But trainees don't prioritize those things. … It's one of the happy things I
do.
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psnet.ahrq.gov/node/33832/psn-pdf
April 01, 2017 - One of the things that we do not discuss a lot (because we
pretty much take it for granted) is that … Because small things are going to come up, so you
have to adjust. … You want to pay attention to what things look like right now. … Because if we know how
things are operating right now and where our vulnerabilities are, we can make … Those kinds of things are really going to contribute to rescuing and making
https://psnet.ahrq.gov/issue
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psnet.ahrq.gov/node/33776/psn-pdf
January 01, 2015 - But all of the things you mention
there—PDSA cycles, root cause analysis, problem solving, continuous … Deming because we see those same things in the Toyota or Lean approach. … When an organization listens to those people and then helps them fix things, these are the cultural themes … the
details of their process improvements, even sometimes what they prioritize in terms of making things … That's one of the most powerful things when the health care folks see that and wonder how much better
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psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
August 01, 2012 - One of the nice things about working in the nursing home world is the availability of secondary datasets … Built on that, some vendors have put in things like scheduling software and accounts software. … Now nursing homes have to deal with some things that might be somewhat different from hospitals, such … That is one of the tough things that nursing homes have to deal with. … Nursing homes are trying to improve the reputation and the kind of things they do.
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psnet.ahrq.gov/node/33762/psn-pdf
March 01, 2014 - that more recently have been taken on board are the
need for multidisciplinary networks, embedding things … That framework was incredibly useful, but it also stifled the opportunity to look at other things
beyond … Other things are being developed that can be used to talk through
algorithms for when antibiotics should … The infection prevention side of things is really universal and international. … RW: I remember 10 years ago people were talking about rotating antibiotics and all sorts of things.
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psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
July 10, 2024 - One of the things I know you're interested in is what can the federal government in particular bring … RW : The more general experience is that things often don't scale. … Together, if both of those directions can be considered simultaneously, the ability to move things more … How do you take advantage of things like checklists and structures but also change the culture at scale … RW : Any other things that you want to talk about?
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psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
August 01, 2012 - Built on that, some vendors have put in things like scheduling software and accounts software. … Those are three things that you might not have seen in many American hospitals 20 or 30 years ago, but … Now nursing homes have to deal with some things that might be somewhat different from hospitals, such … That is one of the tough things that nursing homes have to deal with. … Nursing homes are trying to improve the reputation and the kind of things they do.
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psnet.ahrq.gov/issue/deep-medicine-how-artificial-intelligence-can-make-healthcare-human-again
January 07, 2019 - February 6, 2018
The Checklist Manifesto: How to Get Things Right. … July 22, 2019
Why Things Bite Back: Technology and the Revenge of Unintended Consequences
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psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-walji-phd
December 22, 2020 - MW: One of the first things that we did was that we asked dentists to name the kinds of bad things they … But there are also things like wrong tooth extraction, which people mentioned but don’t seem to come … We may find small things that are more traditionally in errors in the medical settings. … What you are afraid of and what is in reality happening are two different things. … I also think that that one of the things you're talking about is education.
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psnet.ahrq.gov/perspective/adverse-events-dentistry
December 22, 2020 - MW: One of the first things that we did was that we asked dentists to name the kinds of bad things they … But there are also things like wrong tooth extraction, which people mentioned but don’t seem to come … We may find small things that are more traditionally in errors in the medical settings. … What you are afraid of and what is in reality happening are two different things. … I also think that that one of the things you're talking about is education.
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psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
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 … 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. … Why Things Bite Back: Technology and the Revenge of Unintended Consequences.
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psnet.ahrq.gov/perspective/conversation-jeffrey-starke-md
September 11, 2023 - Even if you do go to work when you're ill, you can do things to protect patients, particularly the most … You cannot work well when you have those things. … We've already made some progress with fatigue, and equating those things is exactly the right answer.
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
October 24, 2021 - Things like that are a problem today. … MC : Well, one of the things I'd like to talk about is deployment of pharmacists right now in the United … Maybe things are a little different in California than in Pennsylvania, but it's a pretty rare thing … published it in your newsletter or in the journals, and years later they look back and see several things … That could make things quite a bit safer. That's what I would do if I was redesigning.
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psnet.ahrq.gov/issue/there-no-such-thing-nonjudgmental-debriefing-theory-and-method-debriefing-good-judgment
December 19, 2014 - Commentary
There is no such thing as a "nonjudgmental" debriefing: a theory and method for debriefing with good judgment.
Citation Text:
Rudolph JW, Simon R, Dufresne RL, et al. There's no such thing as "nonjudgmental" debriefing: a theory and method for debriefing with good judgment. Si…
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psnet.ahrq.gov/node/33809/psn-pdf
June 01, 2016 - And
that's true for most things in life. … GM: First of all, in general I am incredibly bullish on the direction things are going. … RW: Where do you see things going and what do you think might be the next big things in this field? … GM: You asked me about things that surprised me over time with patient safety.
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psnet.ahrq.gov/node/33878/psn-pdf
April 01, 2019 - How are things
organized there?
… For example, in criminal law we have things called victim impact statements,
where the victim of the … Similar
things were happening in different areas of law. … Some patients want an apology and other things. … Because the CRP staff would say
things like our approach is "Don't wait for the demand.