Beyond "see one, do one, teach one": toward a different training paradigm.

J M Rodriguez-Paz; M Kennedy; E Salas; A W Wu; J B Sexton; E A Hunt; P J Pronovost

Commentary

Beyond "see one, do one, teach one": toward a different training paradigm.

February 25, 2009

Rodriguez-Paz JM, Kennedy M, Salas E, et al. Qual Saf Health Care. 2009;18(1):63-8.

View more articles from the same authors.

This commentary reviews how the current method for educating physicians-in-training affects patient safety and recommends an alternate teaching model incorporating safety culture.

PubMed citation

Available at

Related Resources From the Same Author(s)

A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety.

January 21, 2009

Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center.

March 6, 2005

A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.

February 11, 2009

Variation in caregiver perceptions of teamwork climate in labor and delivery units.

July 5, 2006

Error, stress, and teamwork in medicine and aviation: cross sectional surveys.

December 21, 2005

Medical error: the second victim.

March 9, 2011

Assessing safety culture: guidelines and recommendations.

August 17, 2005

Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections.

June 14, 2017

Ethics, oversight and quality improvement initiatives.

August 25, 2010

What is the patient really taking? Discrepancies between surgery and anesthesiology preoperative medication histories.

December 21, 2005

How house officers cope with their mistakes.

March 6, 2005

Do house officers learn from their mistakes?

March 6, 2005

The Daily Goals Communication Sheet: a simple and novel tool for improved communication and care.

October 8, 2008

ReCASTing the RCA: an improved model for performing root cause analyses.

May 26, 2010

Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes.

January 16, 2008

Time for transparent standards in quality reporting by health care organizations.

August 16, 2017

Using incident reporting to improve patient safety: a conceptual model.

March 28, 2007

Creating high reliability in health care organizations.

December 20, 2006

Novel analysis of clinically relevant diagnostic errors in point-of-care devices.

October 19, 2011

A framework for encouraging patient engagement in medical decision making.

August 29, 2012

Ethical and practical aspects of disclosing adverse events in the emergency department.

October 4, 2006

Core competencies for patient safety research: a cornerstone for global capacity strengthening.

February 2, 2011

A pediatric medical emergency team manages a complex child with hypoxia and a worried parent.

March 28, 2007

Team training: implications for emergency and critical care pediatrics.

May 28, 2008

Disclosing medical errors to patients: it's not what you say, it's what they hear.

July 22, 2009

Patient-assisted incident reporting: including the patient in patient safety.

June 1, 2011

Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery.

April 3, 2005

A morning briefing: setting the stage for a clinically and operationally good day.

August 10, 2005

Delays and errors in cardiopulmonary resuscitation and defibrillation by pediatric residents during simulated cardiopulmonary arrests.

October 14, 2009

Conflict of interest, Dr Charles Denham and the Journal of Patient Safety.

December 3, 2014

Patient safety reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human.'

August 12, 2015

Mitigating the July effect.

July 7, 2021

Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial.

June 20, 2007

Prescription opioid analgesics commonly unused after surgery: a systematic review.

August 9, 2017

COVID-19: the dark side and the sunny side for patient safety.

October 14, 2020

The role of South--North partnerships in promoting shared learning and knowledge transfer.

September 6, 2017

Toward learning from patient safety reporting systems.

January 10, 2007

Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century.

March 1, 2006

Effectiveness and efficiency of root cause analysis in medicine.

February 27, 2008

How will we know patients are safer? An organization-wide approach to measuring and improving safety.

June 7, 2006

Planning and implementing a systems-based patient safety curriculum in medical education.

August 13, 2008

A check-up for safety culture in "my patient care area."

November 14, 2007

Reducing health care hazards: lessons from the Commercial Aviation Safety Team.

April 15, 2009

Misdiagnosis in the emergency department: time for a system solution.

February 8, 2023

Diagnostic errors, health disparities, and artificial intelligence: a combination for health or harm.

September 1, 2021

Structuring feedback and debriefing to achieve mastery learning goals.

May 18, 2016

Critical incident stress debriefing after adverse patient safety events.

August 9, 2017

Medical error: the second victim.

November 21, 2012

Safety culture in Indian hospitals: a cultural adaptation of the Safety Attitudes Questionnaire.

May 21, 2014

Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children.

May 13, 2009

Does one size fit all? Assessing the need for organizational second victim support programs.

April 7, 2021

What can patient safety teach us about clinician burnout?

January 8, 2020

Close calls in patient safety: should we be paying closer attention?

May 15, 2013

Medical error, incident investigation and the second victim: doing better but feeling worse?

April 4, 2012

Electromagnetic interference from radio frequency identification inducing potentially hazardous incidents in critical care medical equipment.

July 2, 2008

Massive open online course (MOOC) learning builds capacity and improves competence for patient safety among global learners: a prospective cohort study.

September 8, 2021

Health system leaders' role in addressing racism: time to prioritize eliminating health care disparities.

February 10, 2021

What to do with healthcare incident reporting systems.

January 29, 2014

Emotional influences in patient safety.

October 20, 2010

Clinician mindfulness and patient safety.

December 15, 2010

Developing a measure of value in health care.

June 1, 2016

Remote patient monitoring during COVID-19: an unexpected patient safety benefit.

March 23, 2022

Rapid response teams—walk, don't run.

October 11, 2006

Integrating the intensive care unit safety reporting system with existing incident reporting systems.

October 5, 2005

Putting the patient in patient safety investigations: barriers and strategies for involvement.

June 3, 2020

Do hospitals support second victims? Collective insights from patient safety leaders in Maryland.

July 19, 2017

On higher ground: ethical reasoning and its relationship with error disclosure.

April 24, 2013

How to discuss errors and adverse events with cancer patients.

June 16, 2010

COVID-19: peer support and crisis communication strategies to promote institutional resilience.

April 22, 2020

RISE: exploring volunteer retention and sustainability of a second victim support program.

February 3, 2021

Risk factors for clinically relevant deviations in patients' medication lists reported by patients in personal health records: a prospective cohort study in a hospital setting.

March 2, 2022

Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children's center.

February 20, 2008

Review of alternatives to root cause analysis: developing a robust system for incident report analysis.

September 18, 2019

Disclosure of patient safety incidents: a comprehensive review.

September 1, 2010

Development and evaluation of a 3-day patient safety curriculum to advance knowledge, self-efficacy and system thinking among medical students.

April 18, 2012

Measures of patient safety in developing and emerging countries: a review of the literature.

March 17, 2010

"That was a close call": endorsing a broad definition of near misses in health care.

October 2, 2013

How to develop a second victim support program: a toolkit for health care organizations.

May 2, 2012

Health care workers as second victims of medical errors.

May 11, 2011

Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii.

January 30, 2013

Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study.

October 3, 2007

A system factors analysis of "line, tube, and drain" incidents in the intensive care unit.

August 24, 2005

The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research.

April 19, 2006

A visual medication schedule to improve anticoagulation control: a randomized, controlled trial.

October 17, 2007

Adverse-event-reporting practices by US hospitals: results of a national survey.

January 7, 2009

Patient and family empowerment as agents of ambulatory care safety and quality.

September 7, 2016

Disclosure of "nonharmful" medical errors and other events: duty to disclose.

March 29, 2012

Residency schedule, burnout and patient care among first-year residents.

September 4, 2013

Supporting second victims of patient safety events: shouldn't these communications be covered by legal privilege?

February 12, 2014

The aspects of healthcare quality that are important to health professionals and patients: a qualitative study.

December 15, 2021

Adverse effects of the Medicare PSI-90 hospital penalty system on revenue-neutral hospital-acquired conditions.

September 5, 2018

Time of day effects on the incidence of anesthetic adverse events.

August 23, 2006

Medication reconciliation in ambulatory care: attempts at improvement.

October 28, 2009

Psychological and psychosomatic symptoms of second victims of adverse events: a systematic review and meta-analysis.

May 1, 2019

To tell the truth: ethical and practical issues in disclosing medical mistakes to patients.

March 6, 2005

Hospital patient safety grades may misrepresent hospital performance.

February 12, 2014

Peer support for nurses as second victims: resilience, burnout, and job satisfaction.

November 20, 2019

Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study.

October 26, 2016

Case: a second victim support program in pediatrics: successes and challenges to implementation.

March 21, 2018

Implementation of safeguards to improve patient safety in chemotherapy.

September 20, 2017

Related Resources

Assertive communication training for nurses to speak up in cases of medical errors: a systematic review and meta-analysis.

June 14, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Pursuit of "endpoint diagnoses" as a cognitive forcing strategy to avoid premature diagnostic closure.

December 21, 2022

Affective influences on clinical reasoning and diagnosis: insights from social psychology and new research opportunities.

October 19, 2022

Narrowing the mindware gap in medicine.

July 20, 2022

The Safety Competencies Framework.

October 5, 2021

Obstetric iatrogenesis in the United States: the spectrum of unintentional harm, disrespect, violence, and abuse.

September 8, 2021

Racism in pain medicine: we can and should do more.

July 14, 2021

Communication about medical errors.

February 24, 2021

The critical need for nursing education to address the diagnostic process.

February 17, 2021

Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a community-based medical school.

January 20, 2021

Creating a framework to integrate residency program and medical center approaches to quality improvement and patient safety training

January 13, 2021

Improving hospital safety culture for falls prevention through interdisciplinary health education.

December 23, 2020

Misdiagnosis and failure to diagnose in emergency care: causes and empathy as a solution.

November 11, 2020

Systems thinking for managing COVID-19 in health care systems: seven key messages.

September 23, 2020

The role of cognitive bias in breast radiology diagnostic and judgment errors.

May 27, 2020

Patient Safety Primers

Maternal Safety

September 7, 2019

Teaching nurses to make clinical judgments that ensure patient safety.

August 14, 2019

Ten ways to improve medication safety in community pharmacies.

August 7, 2019

Evidence Brief: Implementation of High Reliability Organization Principles.

July 24, 2019

The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes.

July 10, 2019

Reducing three infections across cardiac surgery programs: a multisite cross-unit collaboration.

May 22, 2019

Laney's story: the problem of delayed diagnosis of pediatric stroke.

April 24, 2019

Saving without compromising: teaching trainees to safely provide high value care.

April 17, 2019

Teaching patient safety in global health: lessons from the Duke Global Health Patient Safety Fellowship.

April 17, 2019

Addressing medicine's bias against patients who are overweight.

March 27, 2019

I-PASS mentored implementation handoff curriculum: champion training materials.

March 13, 2019

Perspective

Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula

February 1, 2019

Patterns of disrespectful physician behavior at an academic medical center: implications for training, prevention, and remediation.

December 12, 2018

Principles for Patient and Family Partnership in Care: An American College of Physicians Position Paper.

December 5, 2018

See More About The Topic

General Hospitals

Educators

Culture of Safety

Education and Training

Beyond "see one, do one, teach one": toward a different training paradigm.

Maternal Safety

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Beyond "see one, do one, teach one": toward a different training paradigm.

Maternal Safety

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site