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psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
August 01, 2017 - .… I'm now going to turn to the errors we made in treating this man. … How does the work of registry data collection and analysis change, and where is that going over the next … also the practicality of that—would there be less engagement with these systems if you knew it was going … If you don't have the skills, you're not going to do hepatobiliary surgery. … You're going to go do something more straightforward.
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psnet.ahrq.gov/issue/are-vital-home-health-workers-now-safety-threat
March 28, 2018 - March 27, 2019
‘You’re going to release him when he was hurting himself?’
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psnet.ahrq.gov/issue/how-has-current-economy-affected-patient-safety
May 07, 2018 - Part II: where we're going.
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psnet.ahrq.gov/issue/inattentional-blindness-what-captures-your-attention
May 07, 2018 - Part II: where we're going.
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psnet.ahrq.gov/issue/building-case-medication-reconciliation
June 10, 2018 - Part II: where we're going.
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psnet.ahrq.gov/issue/medication-errors-common-hospital-diabetes
May 13, 2009 - August 5, 2020
A nursing home’s 64-day Covid siege: ‘They’re all going to die’.
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psnet.ahrq.gov/issue/nurses-say-stress-interferes-caring-their-patients
August 29, 2018 - December 15, 2017
Going to the hospital? Don't forget to pack a nurse.
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psnet.ahrq.gov/issue/10-leadership-mindsets-high-reliability-organizations-how-empower-caregivers-and-engage
August 12, 2020 - Part II: where we're going.
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psnet.ahrq.gov/issue/25-year-old-teacher-died-after-waiting-hours-er-shes-not-only-one-who-saw-delays
September 09, 2020 - January 18, 2023
‘You’re going to release him when he was hurting himself?’
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psnet.ahrq.gov/issue/coronavirus-ravaged-nursing-homes-inspectors-were-not-being-tested
October 14, 2020 - July 22, 2020
A nursing home’s 64-day Covid siege: ‘They’re all going to die’.
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psnet.ahrq.gov/issue/new-cms-hospital-quality-star-ratings-stars-are-not-aligned
May 26, 2021 - Part II: where we're going.
November 13, 2018
The 2016 John M.
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psnet.ahrq.gov/issue/reliability-uncertainty-and-management-error-new-perspectives-covid-19-era
January 12, 2022 - January 18, 2023
Going to the COVID-19 Gemba: using observation and high reliability
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psnet.ahrq.gov/issue/how-columbia-ignored-women-undermined-prosecutors-and-protected-predator-more-20-years
May 31, 2023 - August 17, 2022
‘You’re going to release him when he was hurting himself?’
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psnet.ahrq.gov/issue/medication-bar-coding-scan-or-not-scan
October 19, 2022 - July 19, 2023
Going blank: factors contributing to interruptions to nurses' work and
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psnet.ahrq.gov/issue/staff-warned-about-lack-psychiatric-care-va-clinic-they-couldnt-prevent-tragedy
December 12, 2018 - May 26, 2021
‘You’re going to release him when he was hurting himself?’
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psnet.ahrq.gov/issue/nursing-home-workers-warned-government-about-safety-violations-covid-19-outbreaks-and-deaths
September 15, 2021 - July 22, 2020
A nursing home’s 64-day Covid siege: ‘They’re all going to die’.
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psnet.ahrq.gov/issue/high-reliability-pediatric-heart-centers-always-working-toward-getting-better
September 18, 2024 - August 31, 2022
Going to the COVID-19 Gemba: using observation and high reliability strategies
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psnet.ahrq.gov/node/33688/psn-pdf
October 01, 2009 - I think they tried to ensure that they were as open as
possible about what was going on. … So, going back to King/Drew Medical Center, one of the things that we
thought was really important was … So even if you have systems in place to prevent
problems, if a nurse is going to falsify a chart or … a doctor is going to spy on a patient record and violate
HIPAA and share that information with the news … Is the goal to make it better or at some
point do you just say this is not going to happen?
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psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
December 01, 2006 - dynamics related to patient safety—to the extent that you feel encouraged by your colleagues, you are going … And they all answer the question for themselves: Are you going to feel supported socially and emotionally … nurse in Unit X doesn't really care what the hospital says, so much as how his or her actions are going … So for the hospital with 5000 caregivers, the denominator is not going to be 5000, it's going to be the … They have researchers who put on their "publish or perish" research hats and say, "We're going to add
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psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
December 01, 2006 - dynamics related to patient safety—to the extent that you feel encouraged by your colleagues, you are going … And they all answer the question for themselves: Are you going to feel supported socially and emotionally … nurse in Unit X doesn't really care what the hospital says, so much as how his or her actions are going … So for the hospital with 5000 caregivers, the denominator is not going to be 5000, it's going to be the … They have researchers who put on their "publish or perish" research hats and say, "We're going to add