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101. In Conversation With… Paul H. O'Neill, MPA | PSNet
     psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
     January 01, 2017 - And it was possible with that kind of an idea to engage everyone in the pursuit of excellence if the … It's just astounding to me that they don't seem to understand the idea of wall-to-wall excellence in … They were not quick to pick up on the idea of workplace safety, but they did about 8 or 9 years ago now … When we were sitting at dinner before the prize was awarded, I asked him, "Do you have any idea what

102. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33752/psn-pdf
     August 01, 2013 - same time, I don't think that people who were tweaking and improving processes in health care had any idea … try to solve that with a generic tool or by throwing everything at folks—that's generally not a good idea … What do you think about that idea? … BS: The idea of the checklist became the symbol of how it happened.

103. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867980/psn-pdf
     March 25, 2025 - measuring-and-improving-diagnostic-safety-primary-care-addressing-twin-pandemics-diagnostic https://psnet.ahrq.gov//#1 Diagnostic excellence is an emerging idea

104. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33617/psn-pdf
     August 01, 2005 - BB: The nurses that I have talked to have been very high on the idea of being able to call an urgent … We cannot hide incompetent practice behind the idea of systems, but we must recognize that systems play

105. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety | PSNet
     psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
     March 01, 2017 - This latter insight may strike some as a revolutionary idea; it suggests that different organizations … To a social scientist, the idea that you would say systems don't include people seems extraordinary—it's … is a real danger that you take a construct like accountability, and you return to a really unhelpful idea … That seems positive to me because the idea that error and harm are directly linked was probably one of … So the idea that error is the appropriate target has been left behind.

106. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33768/psn-pdf
     June 01, 2014 - DdB: This is an area where people tend to have the idea that if we install the computer everything's … I love the idea of a browser plug-in where you could mouse over a word and have something pop up and … The underlying idea here is that the patient and family can indeed be either direct observers of, or

107. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33738/psn-pdf
     December 01, 2012 - The first point is that having a quiet environment is a good idea irrespective of how people are organized … I don't see how people can argue that trying to standardize is not a good idea.

108. In Conversation with…Donald M. Berwick, MD, MPP | PSNet
     psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
     November 01, 2005 - So the general idea is to use leverage to change the world. … Many of them then had to walk the idea through their own boards. So that was amazing to me. … In terms of Rapid Response Teams, the real hard problem here is not whether it's a good idea to spot … I'm not sure we need a tremendous amount of evidence to shore up that idea. … Is this a good idea? Resources are scarce—especially for personnel.

109. Rapid Response Teams: Lessons from the Early Experience | PSNet
     psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
     November 01, 2005 - Is this a good idea? Resources are scarce—especially for personnel. … So the general idea is to use leverage to change the world. … Many of them then had to walk the idea through their own boards. So that was amazing to me. … In terms of Rapid Response Teams, the real hard problem here is not whether it's a good idea to spot … I'm not sure we need a tremendous amount of evidence to shore up that idea.

110. Policies and practices related to the role of board certification and recertification of pediatricians in hospital privileging. | PSNet
     psnet.ahrq.gov/issue/policies-and-practices-related-role-board-certification-and-recertification-pediatricians
     February 03, 2011 - Alcohol and drug testing of health professionals following preventable adverse events: a bad idea

111. ICD-11 for quality and safety: overview of the WHO Quality and Safety Topic Advisory Group. | PSNet
     psnet.ahrq.gov/issue/icd-11-quality-and-safety-overview-who-quality-and-safety-topic-advisory-group
     February 17, 2017 - Alcohol and drug testing of health professionals following preventable adverse events: a bad idea

112. Accidental deaths, saved lives, and improved quality. | PSNet
     psnet.ahrq.gov/issue/accidental-deaths-saved-lives-and-improved-quality
     February 04, 2015 - Alcohol and drug testing of health professionals following preventable adverse events: a bad idea

113. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33862/psn-pdf
     July 01, 2018 - Long story short, I was a second-year medical student, and I had this crazy idea to start a website called … The idea was that there ought to be a place where doctors can post cases in a way that's searchable, … The second one is I had a simple idea around how do you index these cases by different ages, genders … The idea is to create this as a tool for primary care doctors in the front lines of safety net practices

114. How effective are patient safety initiatives? A retrospective patient record review study of changes to patient safety over time. | PSNet
     psnet.ahrq.gov/issue/how-effective-are-patient-safety-initiatives-retrospective-patient-record-review-study
     March 18, 2013 - It also advances the idea that the results highlight some of the limitations of adverse events as a measure

115. Patient mortality during unannounced accreditation surveys at US hospitals. | PSNet
     psnet.ahrq.gov/issue/patient-mortality-during-unannounced-accreditation-surveys-us-hospitals
     August 03, 2022 - Alcohol and drug testing of health professionals following preventable adverse events: a bad idea

116. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33708/psn-pdf
     March 01, 2011 - As a result, no one ever really focused on this issue until it was forced upon us, because the idea … issues where you have little common ground, the new admission, for example, who the receiver has no idea … RW: So we've moved away from the idea that there's one way to do handoffs. … VA: Yes, that's very consistent with this idea, and as you allude to, the ACGME 2011 Common Program

117. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33760/psn-pdf
     February 01, 2014 - EC: That's a good idea, but it's too late if you begin to actively engage with the interruption task. … They are very focused around the idea that the clinical record is primary and therefore all work needs … But that's a broken idea—technology demanding that work fits around its limitations. … The idea that I can put on a set of spectacles that display task-specific information as I walk through

118. In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring | PSNet
     psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
     April 26, 2023 - But we now also have antilock brakes that let you maintain control on an icy day, which is the idea of … The idea that someone could die in the hospital, with all the doctors and nurses around, from something … This is the idea of serious but treatable complications, and respiratory arrests due to opioids are a … Susan McGrath: That points back to the idea that it’s a system and has various components, not just … Susan McGrath: I think the idea of having engineers be involved in healthcare system design is very

119. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867769/psn-pdf
     March 12, 2025 - Lessons from Event Reports. March 12, 2025 Lessons from Event Reports. Patient Safety Authority. https://psnet.ahrq.gov/issue/lessons-event-reports Small successes can inform and motivate actions leading to sustainable, evidence-based change. This searchable collection of projects initiated in response to event re…

120. Rediscovering the Power of the Surgical M&M Conference: The M M Matrix | PSNet
     psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
     September 01, 2007 - We became frustrated after we realized in the last several years that we had no idea if we were making … For example, the idea of washing hands, it's not something we think about at all, until I realized that