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221. Human Factors Engineering Can Teach You How to Be Surprised Again | PSNet
     psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
     November 01, 2006 - basis.( 10 ) The business literature on using surprise as a catalyst for creativity is in line with the idea … Lau, a human factors engineer at VA National Center for Patient Safety, provided the author with the idea … So one idea is to try to introduce naturalistic sounds and peripheral displays into electronic devices

222. The Safety of Medical Devices | PSNet
     psnet.ahrq.gov/perspective/safety-medical-devices
     June 01, 2011 - ET : I don't think it's necessarily a bad idea. … RW : Checklists are a very hot issue in health care, the idea that things that we've relied on human … ET : I like the idea of checklists up to a point.

223. The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. | PSNet
     psnet.ahrq.gov/issue/fearless-organization-creating-psychological-safety-workplace-learning-innovation-and-growth
     May 16, 2012 - Book/Report Classic The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. Citation Text: The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. Edm…

224. Reducing Adverse Drug Events. | PSNet
     psnet.ahrq.gov/issue/reducing-adverse-drug-events
     August 09, 2017 - Book/Report Classic Reducing Adverse Drug Events. Citation Text: Reducing Adverse Drug Events. Leape LL, Kabcenell A, Berwick DM et al. Boston, MA: Institute for Healthcare Improvement; 1998. Copy Citation Save Save to your library …

225. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. | PSNet
     psnet.ahrq.gov/issue/improvement-guide-practical-approach-enhancing-organizational-performance-2nd-ed
     November 29, 2017 - Book/Report Classic The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. Citation Text: The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. Langley GJ, Moen R, Nolan KM, et al. Ho…

226. What have we learned about interventions to reduce medical errors? | PSNet
     psnet.ahrq.gov/issue/what-have-we-learned-about-interventions-reduce-medical-errors
     June 26, 2019 - Review What have we learned about interventions to reduce medical errors? Citation Text: Woodward HI, Mytton OT, Lemer C, et al. What have we learned about interventions to reduce medical errors? Annu Rev Public Health. 2010;31:479-97 1 p following 497. doi:10.1146/annurev.publhealth.0…

227. Why patients need leaders: introducing a ward safety checklist. | PSNet
     psnet.ahrq.gov/issue/why-patients-need-leaders-introducing-ward-safety-checklist
     October 28, 2020 - Commentary Why patients need leaders: introducing a ward safety checklist. Citation Text: Amin Y, Grewcock D, Andrews S, et al. Why patients need leaders: introducing a ward safety checklist. J R Soc Med. 2012;105(9):377-83. doi:10.1258/jrsm.2012.120098. Copy Citation Format: …

228. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33885/psn-pdf
     August 01, 2019 - Once we started having a scribe for physicians, the idea that we were going to take away the scribe … Any idea of how the patients accept this?

229. Quality and the health system: becoming a high reliability organization. | PSNet
     psnet.ahrq.gov/issue/quality-and-health-system-becoming-high-reliability-organization
     November 16, 2022 - Review Quality and the health system: becoming a high reliability organization. Citation Text: Gaw M, Rosinia F, Diller T. Quality and the health system: becoming a high reliability organization. Anesthesiol Clin. 2018;36(2):217-226. doi:10.1016/j.anclin.2018.01.010. Copy Citation …

230. Imagining improved interactions: patients' designs to address implicit bias. | PSNet
     psnet.ahrq.gov/issue/imagining-improved-interactions-patients-designs-address-implicit-bias
     March 27, 2019 - Study Imagining improved interactions: patients' designs to address implicit bias. Citation Text: Imagining improved interactions: patients' designs to address implicit bias. Yang C, Coney L, Mohanraj D, et al. AMIA Annu Symp Proc. 2023;2023:774-783. Copy Citation Sav…

231. Structural and organizational issues in patient safety: a comparison of health care to other high-hazard industries. | PSNet
     psnet.ahrq.gov/issue/structural-and-organizational-issues-patient-safety-comparison-health-care-other-high-hazard
     February 09, 2011 - Commentary Classic Structural and organizational issues in patient safety: a comparison of health care to other high-hazard industries. Citation Text: Structural and organizational issues in patient safety: a comparison of health care to other high-hazard indust…

232. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74252/psn-pdf
     January 12, 2022 - And when there was a challenge to patient safety, there was action to resolve it, and no idea was a … bad idea.

233. Finding antecedents of psychological safety: a step toward quality improvement. | PSNet
     psnet.ahrq.gov/issue/finding-antecedents-psychological-safety-step-toward-quality-improvement
     October 02, 2013 - Review Finding antecedents of psychological safety: a step toward quality improvement. Citation Text: Aranzamendez G, James D, Toms R. Finding Antecedents of Psychological Safety: A Step Toward Quality Improvement. Nurs Forum. 2015;50(3):171-178. doi:10.1111/nuf.12084. Copy Citation …

234. What's the difference between a hospital and a bottling factory? | PSNet
     psnet.ahrq.gov/issue/whats-difference-between-hospital-and-bottling-factory
     October 08, 2008 - Commentary What's the difference between a hospital and a bottling factory? Citation Text: Morton A, Cornwell J. What's the difference between a hospital and a bottling factory? BMJ. 2009;339(jul20 1). doi:10.1136/bmj.b2727. Copy Citation Format: DOI Google Scholar BibTeX…

235. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33635/psn-pdf
     July 01, 2006 - In Conversation with...Allan Frankel, MD July 1, 2006 In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withallan-frankel-md Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about how you became interested in this kind of work. Dr. Allan …

236. In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd
     February 26, 2025 - This all taps into this idea of trying to address the needs of the injured or harmed person. … The patients and families were not sympathetic to that idea at all.

237. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33730/psn-pdf
     June 01, 2012 - The idea was to aggregate the existing reporting systems and learn lessons nationally. … One is the idea that you can manage things entirely by top-down control.

238. What Have We Learned About Safe Inpatient Handovers? | PSNet
     psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
     March 01, 2011 - As a result, no one ever really focused on this issue until it was forced upon us, because the idea that … 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

239. In Conversation with…Barbara A. Blakeney, MS, RN | PSNet
     psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
     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

240. What went right: lessons for the intensivist from the crew of US Airways Flight 1549. | PSNet
     psnet.ahrq.gov/issue/what-went-right-lessons-intensivist-crew-us-airways-flight-1549
     February 23, 2009 - Commentary What went right: lessons for the intensivist from the crew of US Airways Flight 1549. Citation Text: Eisen LA, Savel RH. What went right: lessons for the intensivist from the crew of US Airways Flight 1549. Chest. 2009;136(3):910-917. doi:10.1378/chest.09-0377. Copy Citation…