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psnet.ahrq.gov/node/72495/psn-pdf
November 25, 2020 - 19-epidemic-national-survey
https://psnet.ahrq.gov/issue/nursing-homes-64-day-covid-siege-theyre-all-going-die
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psnet.ahrq.gov/node/73709/psn-pdf
September 15, 2021 - crisis-management-surgical-teams-and-their-leaders-lessons-covid-19-pandemic-structured
https://psnet.ahrq.gov/issue/going-covid
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psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
July 10, 2024 - That's why we put the very important modifier in the goal that we were going to achieve a 40% reduction … When I was in practice in the 1990s, it always seemed that information was going in one direction—that … We realized that the data from the field was going to be hard to analyze. … We were going for large-scale and quick results, and we allowed flexibility. … does that change your thinking and the Agency's thinking about the way to structure these programs going
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psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
February 26, 2025 - And what I discovered is that they were never going to change because of me. … They were never going to respond to Intermountain. … I can't tell you how gratified I feel to see my students going out and changing the world. … This is one of those tipping point phenomena, and it's going to pick up a lot more speed as it moves … But that as your education level comes up, fundamentally, senior management doesn't know what's going
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psnet.ahrq.gov/node/867653/psn-pdf
February 26, 2025 - At the same time, if we have leaders who are punitive in their response to events, we are not going … At the same time, when we go out and interview staff
in those organizations, they are not going to tell … As a
patient safety manager, it’s not the right approach to say “I’m going to change the way that we … do root
cause analysis, but I’m not going to talk to the risk management staff because they probably … If we have staff that
feel harmed emotionally and physically, they are not going to be able to take
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - Do we have ways to check if we are going off the rails built into the
process? … Not every organization is
going to have that kind of leader. … We looked at
implementations of high reliability in a system that did not go great, but in not going … Tim Vogus: I am not going to give big, sweeping pronouncements here because of the limitations we
talked … will scale up
to being a highly reliable hospital,” we have to work on how we are going to marshal
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psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
October 01, 2008 - So if the hospital is going to be tagged with an adverse event that happened at another place, that's … So we're going to have to have the equivalent of the Hertz guy walking around the patients looking at … I don't think that's what Medicare intends, but I think that's the risk of going too far and too fast … RW: The overall policy direction is so sensible that I cannot see it going away. … That's where we need to be investing if we're going to promote patient safety.
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psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
June 01, 2010 - says something about the covert nature of error in medicine that I really wasn't aware of what was going … Once I became aware of things that were going wrong, I began to look outside of medicine and to other … What's going through your brain that's not going through that person's brain? … PC: When I came into emergency medicine, nobody sat me down and said, this is what your life is going … To be frank with people and let them know what's coming and the sorts of failures that they're going
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psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - The change in paradigm is going to encourage radiologists to slow down and take more time to ensure they … make fewer mistakes, but it’s not going to make the volume of work go away. … AI is not going to be reading an MRI of the abdomen instead of a radiologist any time soon. … KH: Do you think AI is a passing trend that is going to be too overwhelming to adopt in the long-term … That is all to say I don’t think AI is going away. This is here. This is now.
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psnet.ahrq.gov/node/854817/psn-pdf
October 25, 2023 - organizational leaders visiting hospital wards to hear
directly from frontline staff about concerns and what is going
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psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
November 01, 2006 - For example, the anesthesiologist may review beforehand what is going to be needed. … We need to know that we're nearing that point where, if we don't react, some danger is going to happen … Today, if the surgeon or the anesthesiologist wants to know what's going on, they have to take their … Some of the new airlines have decided that they're simply going to buy one airplane from now on. … Automation is not going to succeed without standardization.
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psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
November 01, 2006 - For example, the anesthesiologist may review beforehand what is going to be needed. … We need to know that we're nearing that point where, if we don't react, some danger is going to happen … Today, if the surgeon or the anesthesiologist wants to know what's going on, they have to take their … Some of the new airlines have decided that they're simply going to buy one airplane from now on. … Automation is not going to succeed without standardization.
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psnet.ahrq.gov/node/854249/psn-pdf
January 01, 2014 - https://psnet.ahrq.gov/issue/what-safety-science
https://psnet.ahrq.gov/issue/going-solid-model-system-dynamics-and-consequences-patient-safety
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psnet.ahrq.gov/node/33728/psn-pdf
May 01, 2012 - Focusing on all-cause harm is a really
important transition to make, and it's going to be hard because … DC: That is where future research is probably going to focus. … We're going to see more and more of that research come to bear over the next 5
years. … One strategy may be that we build it but we're not going to spend a fortune on the
type of system that … I think that's going to be a very different view of safety.
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psnet.ahrq.gov/node/853621/psn-pdf
September 20, 2023 - this study found that increases in
potentially inappropriate prescribing increased residents’ risk of going
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psnet.ahrq.gov/node/33720/psn-pdf
November 01, 2011 - There is a lot of medical team training evaluation going on, and I've
been reviewing some of them. … You project very quickly what's going to happen
after you make that mistake—when golfers kneel down … Other things that are happening—I think we're going to use more and more
technology no matter what. … Technology is going to evolve, and the technology is doing more and more
of the thinking for us. … I think in 5 years we're going to stop talking about team
training.
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psnet.ahrq.gov/node/866622/psn-pdf
August 28, 2024 - often not psychological
safety to speak up because of the focus on what went wrong and “What are we going … we can
do to enhance learning and bring the walls down, such as a shift in language, is what we're going … when they happen,
but we should also really be mindful that the learning from those situations is going … And third, it’s important to understand that what has gotten us
to this point is not possibly going … outcomes with a
discussion of what went well and if there is someone who should be recognized for going
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psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd
February 26, 2025 - I became aware that we were not going to be able to summarize this area the way we typically summarize … these HIT data, it became apparent that there was no way to summarize this in a simple way that was going … to be meaningful to all users, because the information was going to be so highly dependent on the individual … I think that these same kinds of so-called softer measures are going to be improved most quickly if they … Because what's really going to be most interesting to people who are reading about it is knowing how
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psnet.ahrq.gov/node/73342/psn-pdf
June 02, 2021 - that Positive Leadership WalkRounds – where
leadership conduct rounds and ask staff about what is going
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psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
August 01, 2019 - The first is to make sure that the work going directly to the physician really can only be done by the … That was not going to happen. … "Right now we're just going to do the exam." … That's going to make it more difficult for the scribe and a little bit more difficult to put that note … My underlying principle would be that if it's more fun, people are going to enjoy themselves more and