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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/node/45430/psn-pdf
September 28, 2016 - Understanding and responding when things go wrong:
key principles for primary care educators.
September 28, 2016
McNab D, Bowie P, Ross A, et al. Understanding and responding when things go wrong: key principles for
primary care educators. Educ Prim Care. 2016;27(4):258-66. doi:10.1080/14739879.2016.1205959.
https…
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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/43423/psn-pdf
August 12, 2014 - Deafening silence? Time to reconsider whether
organisations are silent or deaf when things go wrong.
August 12, 2014
Jones A, Kelly D. Deafening silence? Time to reconsider whether organisations are silent or deaf when
things go wrong. BMJ Qual Saf. 2014;23(9):709-13. doi:10.1136/bmjqs-2013-002718.
https://psnet.a…
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psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
March 01, 2013 - done, and we have seen a lot of "paralysis by analysis" as people try to figure out what the ideal thing … Simulation is a perfect thing to do for that interactive and experiential component where we do not yet … One thing to remember is no one doing simulation is suggesting that simulation can replace the traditional … One thing we can do for trainees with simulation is we can allow them to be "it." … However, one thing is clear: More expensive simulators are not necessarily better.
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psnet.ahrq.gov/perspective/conversation-kathleen-sutcliffe-mn-phd
April 26, 2023 - On the other hand, if there's chaos and everybody's doing their own thing to react effectively, how does … 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.
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psnet.ahrq.gov/node/851924/psn-pdf
August 02, 2023 - The things we carry: the scope and impact of second
victim syndrome.
August 2, 2023
Nosanov L, Elseth AJ, Maxwell J, et al. The things we carry: the scope and impact of second victim
syndrome. Am J Surg. 2023;226(5):726-728. doi:10.1016/j.amjsurg.2023.06.035.
https://psnet.ahrq.gov/issue/things-we-carry-scope-and-…
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psnet.ahrq.gov/node/33857/psn-pdf
July 01, 2012 - 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/perspective/literature-health-care-simulation-education-what-does-it-show
March 01, 2013 - However, one thing is clear: More expensive simulators are not necessarily better. … done, and we have seen a lot of "paralysis by analysis" as people try to figure out what the ideal thing … Simulation is a perfect thing to do for that interactive and experiential component where we do not yet … One thing to remember is no one doing simulation is suggesting that simulation can replace the traditional … One thing we can do for trainees with simulation is we can allow them to be "it."
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psnet.ahrq.gov/node/43266/psn-pdf
June 18, 2014 - That's the way we do things around here! Your actions
speak louder than words when it comes to patient safety.
June 18, 2014
Grissinger M. That's the Way We Do Things Around Here!: Your Actions Speak Louder Than Words When
It Comes To Patient Safety. P T. 2014;39(5):308-44.
https://psnet.ahrq.gov/issue/thats-way-w…
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psnet.ahrq.gov/node/44177/psn-pdf
November 10, 2015 - Doing the right things and doing them the right way:
association between hospital guideline adherence, dosing
safety, and outcomes among patients with acute coronary
syndrome.
November 10, 2015
Mehta RH, Chen AY, Alexander KP, et al. Doing the right things and doing them the right way: association
between hospita…
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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/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.
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psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
September 24, 2024 - and punishments, or even just external rewards, reduce people's intrinsic motivation to do the right thing … But when it comes to this kind of zero harm goal, I would just repeat that I think it is not a good thing … We're working together to try to do this safely, quickly, and efficiently, but it's not the kind of thing
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psnet.ahrq.gov/node/33816/psn-pdf
October 01, 2016 - Another thing that took me a while to appreciate in hospital infection control is
understanding where … clinicians and managers immediate feedback in some ways illustrating that a patient is at risk for a bad
thing … happening or a bad thing is starting to happen.
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psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
August 01, 2015 - But the most important thing the government did to get IT up and running, and I think this was actually … So what's the most important thing government could do? … It was the one-more-thing syndrome. … Everyone just added one more thing, the consequence of that is about a thousand one-more-things, and … Whatever it is, there was something important about the interpersonal thing, and we've begun to lose
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psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
August 01, 2015 - But the most important thing the government did to get IT up and running, and I think this was actually … So what's the most important thing government could do? … It was the one-more-thing syndrome. … Everyone just added one more thing, the consequence of that is about a thousand one-more-things, and … Whatever it is, there was something important about the interpersonal thing, and we've begun to lose
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psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
June 01, 2010 - Thinking critically and clearly, especially in an environment like emergency medicine, is not an easy thing … The critical thing for me is to provide the best care here and not to allow my emotions to intrude. … PC: The major thing that we did was to change the nature of our M&M rounds. … Diagnostic acumen, for example, is the one thing that physicians hold very dear. … It's the most important thing to them.
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psnet.ahrq.gov/node/40194/psn-pdf
June 20, 2011 - What happens when things go wrong?
June 20, 2011
Brandom BW, Callahan P, Micalizzi DA. What happens when things go wrong? Paediatr Anaesth.
2011;21(7):730-6. doi:10.1111/j.1460-9592.2010.03513.x.
https://psnet.ahrq.gov/issue/what-happens-when-things-go-wrong
This commentary reveals a personal story of loss and dis…
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psnet.ahrq.gov/perspective/conversation-chris-cebollero-bs-ccemt-p
May 26, 2021 - There are organizations where I’ve had a patient fall in my care and the first thing I had to do was … It's a horrible thing for me to have to sit here and say that an organization is going to retaliate against … I know that I need to do the right thing, but I don't want to be seen as not trustworthy to my crewmates … feel that, “this is my organization, I'm the chief of this organization, the buck stops here” kind of thing … However, that's the thing too—just because you develop a tool, you’ve still got to get people to use