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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/33764/psn-pdf
April 01, 2014 - that we are starting to pay for improved
quality and safety as opposed to volume, which is a good thing … This rapid transition is a good thing. … Another thing is that we're trying to do so much more
to engage and empower patients and make sure they … there's a reasonable
amount of respect among the caregivers and the organization wants to do the right thing
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psnet.ahrq.gov/node/33742/psn-pdf
December 01, 2012 - I talked to various colleagues and the Chief of Medicine and asked, "What's this thing about
these older … The other common pitfall in the elderly—I say this over and over—it's usually not
caused by just one thing … thoughtfully look through
everything and it's probably not going to be solved by just addressing one thing … I said if there is one thing your organization can do is please
create a single code for delirium: have
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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/public-has-been-forgiving-hospitals-got-some-things-wrong
April 03, 2019 - Newspaper/Magazine Article
The public has been forgiving. But hospitals got some things wrong.
Citation Text:
Ofri D. The public has been forgiving. But hospitals got some things wrong. New York Times. 2020; May 21.
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Format:
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psnet.ahrq.gov/issue/graded-autonomy-medical-education-managing-things-go-bump-night
July 22, 2020 - Commentary
Graded autonomy in medical education—managing things that go bump in the night.
Citation Text:
Halpern S, Detsky AS. Graded autonomy in medical education--managing things that go bump in the night. N Engl J Med. 2014;370(12):1086-1089. doi:10.1056/NEJMp1315408.
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psnet.ahrq.gov/node/33694/psn-pdf
April 01, 2010 - calls for harmonization and that different
organizations have their own ways of measuring the same thing … JC: Well, it is, and the other thing is that it's not only daunting, but it has made us realize that … adequate attention can be focused not only on measurement and
reporting, but also on the most important thing
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psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
March 30, 2022 - are defined as "an act of commission (doing something wrong) or omission (failing to do the right thing … term referring to any act of commission (doing something wrong) or omission (failing to do the right thing
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psnet.ahrq.gov/node/33861/psn-pdf
July 01, 2018 - 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/perspective/conversation-withchristine-sinsky-md
February 26, 2025 - As I looked around, I saw that others were experiencing the same thing. … So it could be a negative thing.
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psnet.ahrq.gov/issue/public-reporting-antibiotic-timing-patients-pneumonia-lessons-flawed-performance-measure
May 08, 2017 - example, including the tension that results from having providers balance their desire to do the right thing
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psnet.ahrq.gov/node/33704/psn-pdf
December 01, 2010 - professional narcissism, the good kind, where we go
into this work because we want to do the right thing … them know that you're going to deal straight with them if they'll deal straight with you.The other thing … combine and create a way of making risk management and patient safety part and
parcel of the same thing—to
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psnet.ahrq.gov/node/36625/psn-pdf
November 21, 2016 - When Things Go Wrong: Voices of Patients and Families.
November 21, 2016
CRICO/RMF; Harvard Risk Management Foundation
https://psnet.ahrq.gov/issue/when-things-go-wrong-voices-patients-and-families
This educational video shares patient and family perspectives on how medical error affected their lives.
https://psne…
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psnet.ahrq.gov/node/33750/psn-pdf
May 01, 2013 - inspired by something bigger than financial
incentives, who are going to do this because it's the right thing … The single biggest thing we need is more clinical data because right now we're primarily using
administrative … If I could invest in one thing in patient safety, it would be in coming up with high-quality reliable … For example, if I
really thought electronic health records were the latest and greatest thing and that
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psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
June 01, 2011 - I don't doubt that in preventing surgical errors, operating on the wrong limb, and that kind of thing … that alerts designed to cue people to remember that the patient was allergic to medicine, or to do thing … you can imagine that there probably is someone thinking, "But what about this," or "Isn't this bad thing … I'm not saying that that is necessarily a bad thing; sometimes it's a good thing.
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psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - So I realized that you can do the right thing. Now was I nervous during this? … JB: Well, the biggest thing was the culture. … But that's not so much the safety thing, the way I would define it. … How do you convince people what the right thing to do is? … We look at the problems, and I think this is the important thing.
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psnet.ahrq.gov/node/40280/psn-pdf
June 10, 2018 - That’s the way we do things around here!
June 10, 2018
ISMP Medication Safety Alert! Acute care edition. February 24, 2011;16:1-2.
https://psnet.ahrq.gov/issue/thats-way-we-do-things-around-here
This piece discusses the effects of personal behaviors and peer interactions on an organization’s safety
culture.
https…
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - I don't doubt that in preventing surgical errors, operating on the wrong limb, and that kind of thing … that alerts designed to cue people to remember that the patient was allergic to medicine, or to do thing … you can imagine that there probably is someone thinking, "But what about this," or "Isn't this bad thing … I'm not saying that that is necessarily a bad thing; sometimes it's a good thing.
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psnet.ahrq.gov/node/33626/psn-pdf
January 01, 2006 - Then you also have
to adapt this teamwork behavior to your institution; there's no such thing as one-size-fits-all … Probably the most encouraging thing we've heard was from a surgeon who adapted some of these
behaviors … It was just a simple thing of including the person on the team.
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psnet.ahrq.gov/perspective/conversation-eric-j-topol-md
February 26, 2025 - It is the kind of thing that has made Apple the highest market cap company in the world and led to many … That strikes me as almost the same thing. … That is one thing they should learn. … Actually patients having their data all flowing freely to them, it is a natural thing.