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psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - GS : The most important thing is for people to measure themselves. … One thing we've learned is that stories are very important. … GS : One thing we've tried to do is consider ways to create the infrastructure to support good cognition … GS : One thing I would just stress is how we need to better learn ways to work with uncertainty in diagnosis
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psnet.ahrq.gov/node/42943/psn-pdf
April 12, 2014 - Doing right by our patients when things go wrong in the
ambulatory setting.
April 12, 2014
Schiff G, Griswold P, Ellis BR, et al. Doing right by our patients when things go wrong in the ambulatory
setting. Jt Comm J Qual Patient Saf. 2014;40(2):91-96.
https://psnet.ahrq.gov/issue/doing-right-our-patients-when-thin…
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psnet.ahrq.gov/issue/disclosure-medical-injury-patients-improbable-risk-management-strategy
February 17, 2011 - The authors agree that fully disclosing errors is "the right thing to do," but caution that the financial
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psnet.ahrq.gov/node/49629/psn-pdf
June 01, 2011 - of using read-backs to improve communication, simply issuing a
requirement for them is not the same thing … https://psnet.ahrq.gov//#references
In terms of integrating the process into workflow, the right thing … to do also needs to be the easy thing to do.
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psnet.ahrq.gov/node/33754/psn-pdf
September 01, 2013 - Sidney Dekker: The fascinating thing for me has always been the vast difference in safety performance … problem with making assertions and comparisons like that is that we
take health care to be a monolithic thing … Somebody said, "I trust you to do the right thing." … And by extension what will the hospital do to
learn from this thing and make structural arrangements
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psnet.ahrq.gov/node/33774/psn-pdf
December 01, 2014 - This is the same thing
you've been trying to do which is give people the best quality care possible, … RW: I guess the natural thing for folks in the US to think is it must be really hard doing this work … RW: One thing we confront working at a large health system is that it has big hospitals and little hospitals … have the same issues around staff motivation, too many patients, how to get people to do the right
thing
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psnet.ahrq.gov/perspective/conversation-withsorrel-king
March 01, 2007 - It was a system thing. … From what I see and hear, it's constantly a communication thing. … But the more important thing about that story was that the hospital and the family came together and … The second thing I'm most proud of is all the good stuff that we've done since she's died.
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psnet.ahrq.gov/node/43969/psn-pdf
November 17, 2017 - Transparency when things go wrong: physician attitudes
about reporting medical errors to patients, peers, and
institutions.
November 17, 2017
Bell SK, White AA, Yi JC, et al. Transparency When Things Go Wrong. J Patient Saf. 2015;13(4):243-248.
doi:10.1097/pts.0000000000000153.
https://psnet.ahrq.gov/issue/transp…
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psnet.ahrq.gov/node/44132/psn-pdf
May 13, 2015 - Adverse outcomes: why bad things happen to good
people.
May 13, 2015
Sonnenberg A. Adverse outcomes: why bad things happen to good people. Clin Gastroenterol Hepatol.
2015;13(5):820-3.e1. doi:10.1016/j.cgh.2014.07.064.
https://psnet.ahrq.gov/issue/adverse-outcomes-why-bad-things-happen-good-people
This commentary…
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psnet.ahrq.gov/node/60173/psn-pdf
March 30, 2020 - The final thing that I think is helpful is that we are identifying the setting that the patient safety … SH: What would be the one thing that you recommend somebody to read from the report? … I remember thinking when the WHO checklist came out that finally the
whole world can agree on one thing
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psnet.ahrq.gov/node/43749/psn-pdf
December 10, 2014 - Alarm management: first things first: using reliable data
to eliminate unnecessary alarms.
December 10, 2014
Vanderveen T. Patient Saf Qual Healthc. November/December 2014;11:38-40,42-45.
https://psnet.ahrq.gov/issue/alarm-management-first-things-first-using-reliable-data-eliminate-unnecessary-
alarms
Spotlightin…
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psnet.ahrq.gov/web-mm/say-it-again
January 31, 2020 - of using read-backs to improve communication, simply issuing a requirement for them is not the same thing … In terms of integrating the process into workflow, the right thing to do also needs to be the easy thing
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psnet.ahrq.gov/node/34861/psn-pdf
November 11, 2015 - When things go wrong: how health care organizations
deal with major failures.
November 11, 2015
Walshe K, Shortell SM. When things go wrong: how health care organizations deal with major failures.
Health Aff (Millwood). 2004;23(3):103-11.
https://psnet.ahrq.gov/issue/when-things-go-wrong-how-health-care-organizati…
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psnet.ahrq.gov/node/36964/psn-pdf
March 24, 2011 - Patients use an internet technology to report when things
go wrong.
March 24, 2011
Wasson JH, MacKenzie TA, Hall M. Patients use an internet technology to report when things go wrong.
Qual Saf Health Care. 2007;16(3):213-5.
https://psnet.ahrq.gov/issue/patients-use-internet-technology-report-when-things-go-wrong
…
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psnet.ahrq.gov/issue/openness-and-honesty-when-things-go-wrong-professional-duty-candour
October 04, 2017 - Book/Report
Openness and Honesty When Things Go Wrong: the Professional Duty of Candour.
Citation Text:
Openness and Honesty When Things Go Wrong: the Professional Duty of Candour. London, UK: General Medical Council and the Nursing and Midwifery Council; June 29, 2015.
Copy Citation
…
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psnet.ahrq.gov/node/859646/psn-pdf
January 04, 2024 - Jodi Sherman: Well, I think importantly, we all need to see that this isn’t some future thing. … They have slightly different physiologic effects, but
they achieve the same thing. … That’s one thing
that they’ve done that has helped them to be more successful. … Sarah Mossburg: One thing that you mentioned in one of your articles is that as opposed to single-use
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psnet.ahrq.gov/node/33862/psn-pdf
July 01, 2018 - Almost a decade later, one of my good friends was starting this thing, which at that time
was called … One thing I learned is that everything takes pi plus 2x
longer than you think it's going to take. … One is we just think it's the right thing to do. … People
have this sense of I'm part of something big, and the success of this big thing is my success … about it, but when we're in a room with a patient and they're
coming in with this, that, and the other thing—we're
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psnet.ahrq.gov/issue/improving-ambulatory-patient-safety-learning-last-decade-moving-ahead-next
November 15, 2018 - January 3, 2017
Making it easier to do the right thing: a modern communication QI agenda
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
March 27, 2024 - The other thing is that technologies are a tool, and they don't themselves guarantee a result. … One thing I've concluded from the experience of who naturally and proactively adopted records and who … ratchet that error rate down and would that be a low enough rate so that you could make this whole thing … We had to make an argument around the privacy and security thing that acknowledged that we were going … DB : The thing that turned me into a supporter of the electronic health record was this one application
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psnet.ahrq.gov/node/33832/psn-pdf
April 01, 2017 - On the
other hand, if there's chaos and everybody's doing their own thing to react effectively, how … The other thing that is critical is
this issue of cross-boundary interactions and really understanding … We've been doing this standardizing thing.
There's definitely more room for that.