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psnet.ahrq.gov/issue/respectful-management-serious-clinical-adverse-events-second-edition
January 27, 2016 - developing a culture of safety, and the need for organizations to have a comprehensive crisis plan in place rather … than reacting after events have occurred.
                                     
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psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - Rather, the "soil" must be well prepared and fertile for discovery to take root. … involvement in the investigation process.(3) Administrative and medical staff
leaders must do more than … Rather than pronounce the root cause to be "lack of training" and stop at that point, the team is
encouraged
                                     
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psnet.ahrq.gov/issue/patient-safety-incidents-home-hospice-care-experiences-hospice-interdisciplinary-team-members
February 15, 2011 - error of omission) were the most common concerns, often related to patient or family caregiver actions rather … than the home hospice team.
                                     
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psnet.ahrq.gov/issue/medication-safety-and-administration-intravenous-vincristine-international-survey-oncology
March 26, 2015 - always causes fatal toxicity if it is incorrectly administered intrathecally (via spinal injection) rather … than intravenously.
                                     
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psnet.ahrq.gov/issue/safety-i-safety-ii-and-burnout-how-complexity-science-can-help-clinician-wellness
December 20, 2017 - Building on success rather than reacting to failure is an emerging focus of improvement efforts.
                                     
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psnet.ahrq.gov/issue/failures-communication-through-documents-and-documentation-across-perioperative-pathway
August 07, 2013 - a reliance on written documentation, which was often difficult to find or missing key information, rather … than verbal  signout .
                                     
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psnet.ahrq.gov/issue/board-pharmacy-practices-related-medication-errors-and-their-potential-impact-patient-safety
December 20, 2017 - responses were inconsistent and solutions were mostly focused on education and  disciplinary action  rather … than systems of care.
                                     
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psnet.ahrq.gov/issue/beyond-service-quality-mediating-role-patient-safety-perceptions-patient-experience
January 14, 2011 - patient safety , concerns persist that patient satisfaction may be more influenced by  service quality  rather … than safety issues.
                                     
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psnet.ahrq.gov/issue/triangulating-case-finding-tools-patient-safety-surveillance-cross-sectional-case-study
February 08, 2012 - Similar to a past  study , the authors advocate for a strategy combining detection methods rather than
                                     
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psnet.ahrq.gov/issue/hospital-system-barriers-rapid-response-team-activation-cognitive-work-analysis
September 09, 2015 - study suggested that calling a rapid response is felt to only be justifiable in extreme situations rather … than beforehand, which severely limits the potential effectiveness of this intervention.
                                     
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psnet.ahrq.gov/issue/conditions-influence-impact-malpractice-litigation-risk-physicians-behavior-regarding-patient
January 07, 2015 - behavior and litigation risk: complexity of care, discussion of mistakes among colleagues, personalized rather … than team responsibility, and how hospitals respond to incidents.
                                     
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psnet.ahrq.gov/web-mm/say-it-again
January 31, 2020 - Rather than unnecessarily impose separate protocols on facilities to achieve the two NPSGs, the Table … Rather than relying blindly on the read-back, providers still need to exercise heightened sensitivity … Acceptance of new protocols occurs when there is involvement and ownership at the local-unit level rather … than solely imposed externally.
                                     
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psnet.ahrq.gov/perspective/conversation-kathleen-sutcliffe-mn-phd
April 26, 2023 - Rather than going to a school of public health, I chose to go to a business school, in part because I … We started discussing how this idea of high reliability was probably more generalizable than had been … literature even in non–health care was fairly sparse and more around crisis management, Tylenol, etc. rather … In fact, knowing that we've been on this good run sometimes contributes to less vigilance rather than
                                     
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.143_slideshow.ppt
January 01, 2015 - linear, focused questions based on a succinct chief complaint
	Providers quickly focus in on the problem rather … than identifying the broader agenda
	In practice, only one-third of clinical encounters begin with open-ended … I know my kid better than anyone.” 
	Worried: “Will it heal correctly now?” … Current System: Provider-Centered Care
	Many current systems seem designed to meet needs of providers rather … than patients, supported by varying adoption of patient-centered practices in a recent survey
Audet
                                     
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psnet.ahrq.gov/node/49584/psn-pdf
April 01, 2009 - Rather, the errors were in (i) weak linkages among computer
systems, (ii) insufficient safeguards against … than a gain in clinical insights. … than the kilograms the
software expects. … Implementations are more wrenching than they need to be. … EMRs are undoubtedly better than paper records.
                                     
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psnet.ahrq.gov/node/73998/psn-pdf
October 27, 2021 - and intravenous fluids were infused under pressure into the external jugular
intravenous catheter rather … than the femoral central venous catheter.  … Shorter catheters provide less resistance to flow than longer ones and thus are
preferred when rapid … anesthesiologist in this case chose to place an intravenous catheter in the external
jugular vein rather … than in another large-bore vein such as the saphenous or antecubital vein. 
                                     
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psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
May 11, 2014 - When the ACT returned normal rather than prolonged (as it should have been after the heparin), the anesthesiologist … He quickly realized that the heparin vial from the  garbage  was a 10 units/mL concentration rather than … and three were injured when nurses administered heparin flushes prepared from 10,000 units/mL vials rather … than from similar-looking vials containing the 10 units/mL concentration used to flush intravenous catheters … heparin selections had a four-fold higher incidence of averted programming errors identified by the DERS than
                                     
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psnet.ahrq.gov/node/838222/psn-pdf
September 28, 2022 - measures, primary care practices sometimes look like they have lower quality
metrics; they’re 70% or 80% rather … than 90%. … So rather than trying to measure 100 things, we wonder how
to determine a parsimonious group of measures … If I see patients five times a year, rather than three times a year, then I can’t see as many
patients … It essentially is designed to support the transactional aspects rather than the
relational aspects.
                                     
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psnet.ahrq.gov/issue/interruptions-and-multi-tasking-moving-research-agenda-new-directions
March 23, 2011 - interruptions  in health care, this commentary reveals that most studies focus on the rate of interruptions rather … than the relationship between interruptions and errors.
                                     
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psnet.ahrq.gov/issue/making-healthcare-safer-understanding-designing-and-buying-better-it
February 20, 2019 - can remain unrecognized due to  insufficient reporting  and the tendency to place blame on the user rather … than question whether the equipment  functioned appropriately .