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121. 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

122. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44693/psn-pdf
     June 15, 2016 - Safety. June 15, 2016 Center for Health Design. https://psnet.ahrq.gov/issue/safety-0 Elements of the health care work environment can affect the care delivery. This website highlights design considerations for health care facilities that can help reduce noise, falls, and hospital-acquired infections. The collect…

123. 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

124. 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.

125. 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

126. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34762/psn-pdf
     March 28, 2005 - Diffusion of Innovations. 5th ed. March 28, 2005 Rogers EM. New York NY: Free Press; 2005. https://psnet.ahrq.gov/issue/diffusion-innovations-5th-ed Those who seek to improve the quality and safety of health care would be well served by a deeper understanding of how innovations spread through systems. Rogers first…

127. 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.

128. 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

129. Incorporation of quality and safety principles in maintenance of certification: a qualitative analysis of American Board of Medical Specialties member boards. | PSNet
     psnet.ahrq.gov/issue/incorporation-quality-and-safety-principles-maintenance-certification-qualitative-analysis
     July 18, 2018 - Alcohol and drug testing of health professionals following preventable adverse events: a bad idea

130. 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.

131. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867097/psn-pdf
     November 06, 2024 - Recommendations but no Action: Improving the Effectiveness of Quality and Safety Recommendations in Healthcare. November 6, 2024 Recommendations But No Action: Improving The Effectiveness Of Quality And Safety Recommendations In Healthcare. Dorset, UK: Health Services Safety Investigations Body; September 2024. h…

132. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/863760/psn-pdf
     March 06, 2024 - Imagining improved interactions: patients' designs to address implicit bias. March 6, 2024 Yang C, Coney L, Mohanraj D, et al. AMIA Annu Symp Proc. 2023;2023:774-783. https://psnet.ahrq.gov/issue/imagining-improved-interactions-patients-designs-address-implicit-bias Implicit biases can compromise decision making a…

133. 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

134. 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

135. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34748/psn-pdf
     March 07, 2005 - Reducing Adverse Drug Events. March 7, 2005 Leape LL, Kabcenell A, Berwick DM et al. Boston, MA: Institute for Healthcare Improvement; 1998. https://psnet.ahrq.gov/issue/reducing-adverse-drug-events This application-oriented book provides the results of the Institute for Healthcare Improvement (IHI) Breakthrough S…

136. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45477/psn-pdf
     October 05, 2016 - Promoting safety through well-being: an experience in healthcare. October 5, 2016 Bruno A, Bracco F. Promoting Safety through Well-Being: An Experience in Healthcare. Front Psychol. 2016;7:1208. doi:10.3389/fpsyg.2016.01208. https://psnet.ahrq.gov/issue/promoting-safety-through-well-being-experience-healthcare Th…

137. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35861/psn-pdf
     March 28, 2011 - How can the principles of complexity science be applied to improve the coordination of care for complex pediatric patients? March 28, 2011 Matlow AG, Wright JG, Zimmerman B, et al. How can the principles of complexity science be applied to improve the coordination of care for complex pediatric patients? Qual Saf H…

138. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-472
     February 26, 2025 - Failure-to-rescue (FTR) refers to the idea that many complications of medical care are not preventable … Failure-to-rescue (FTR) refers to the idea that many complications of medical care are not preventable

139. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47429/psn-pdf
     December 05, 2018 - The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. December 5, 2018 Edmondson AC. Hoboken, NJ: John Wiley & Sons, Inc.; 2019. ISBN: 9781119477266. https://psnet.ahrq.gov/issue/fearless-organization-creating-psychological-safety-workplace-learning- innova…

140. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40342/psn-pdf
     April 21, 2015 - Counterheroism, common knowledge, and ergonomics: concepts from aviation that could improve patient safety. April 21, 2015 Lewis GH, Vaithianathan R, Hockey PM, et al. Counterheroism, common knowledge, and ergonomics: concepts from aviation that could improve patient safety. Milbank Q. 2011;89(1):4-38. doi:10.1111/…