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psnet.ahrq.gov/node/33822/psn-pdf
January 01, 2017 - Another thing that was really important in the case of Alcoa was we had 143,000 people in 43 countries … You know, it's a curious thing that I found really strange. … That is a really good thing. … Another thing in health care: the reporting is terrible. … One
thing you have to do is beat back the legal staff who don't want you to tell anybody that there
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psnet.ahrq.gov/node/33734/psn-pdf
August 01, 2012 - Now whether this was a causal thing, whether
the Joint Commission facilitated that, or whether those … NC: Yeah, and that's the curious thing. … It wasn't an influx of resources; it was
purely a leadership thing. … One thing that happened
over time was nursing homes became very medicalized. … But one thing that you really cannot improve is: for many residents this is
their last place.
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psnet.ahrq.gov/node/33648/psn-pdf
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/issue/internet-things-healthcare-patient-safety-empirical-study
March 18, 2020 - Study
Internet of things in healthcare for patient safety: an empirical study.
Citation Text:
Yesmin T, Carter MW, Gladman AS. Internet of things in healthcare for patient safety: an empirical study. BMC Health Serv Res. 2022;22(1):278. doi:10.1186/s12913-022-07620-3.
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psnet.ahrq.gov/issue/doing-right-things-correct-wrong-site-surgery
October 21, 2020 - Newspaper/Magazine Article
Doing the "right" things to correct wrong-site surgery.
Citation Text:
Doing the "right" things to correct wrong-site surgery. Patient Safety Advisory
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psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp
October 30, 2019 - The fork-in-the-road choice is between the right thing to do and the easy thing to do. … to do also the easy thing to do. … And sometimes the right thing to do is to do a C-section. … But the hardest thing about the C-section problem is that the right answer is not zero. … The only thing it does reliably is increase C-section rates because it can tell us information.
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psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
September 01, 2011 - Another thing is that it's a common problem for which there isn't a single great solution, so it's not … But the more general point is that, once you decide this thing is prevalent, you stop doing isolated … That's an ethically good thing to do and a wise thing to do. … The initial spike is usually a good thing and shows more engagement and more attention to it. … With anything else, you could have the same thing achieved other ways.
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psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - But the more general point is that, once you decide this thing is prevalent, you stop doing isolated … That's an ethically good thing to do and a wise thing to do. … The initial spike is usually a good thing and shows more engagement and more attention to it. … Some people go into the executive walk rounds with just the PR thing—like let's show that management … With anything else, you could have the same thing achieved other ways.
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psnet.ahrq.gov/node/853081/psn-pdf
August 30, 2023 - Another thing I saw in your evaluation was
“good catch” measures. … One thing we did was make sure that we identified near-
misses, or when somebody caught something before … The other thing is when they do patient education, they can go over things on the big screen. … Kathy Sanford: The only thing that I would add as a barrier is that the cameras cost money. … I would ask those
groups, “If you could change one thing in healthcare, what would it be?”
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psnet.ahrq.gov/node/33879/psn-pdf
May 01, 2019 - But emergency medical services (EMS) remained
my passion because being in the field is the coolest thing … Let's get to the appropriate center and do the right thing for this guy." "She's having a stroke. … Let's do the right thing." … And that's
one thing that makes it really hard, because 1% of the patients they're going to see will … They can decide what the right thing is to do for this patient in this
scenario.
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psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences
March 20, 2019 - March 29, 2023
"My whole room went into chaos because of that thing in the corner
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psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
October 30, 2019 - The fork-in-the-road choice is between the right thing to do and the easy thing to do. … to do also the easy thing to do. … And sometimes the right thing to do is to do a C-section. … But the hardest thing about the C-section problem is that the right answer is not zero. … The only thing it does reliably is increase C-section rates because it can tell us information.
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psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
February 26, 2025 - That's a good thing for medicine, because these are problems that we should be addressing before they … So change may not necessarily be a bad thing. … The second thing we've seen with safety is what patients find in notes, as you were alluding to. … For one thing, there's a lot you can learn from patients. … The second thing that I've been intrigued by is the idea of OpenNotes as a visit extender.
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psnet.ahrq.gov/issue/what-happens-when-things-go-wrong
April 24, 2018 - Commentary
What happens when things go wrong?
Citation Text:
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.
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psnet.ahrq.gov/issue/getting-it-right-when-things-go-wrong
October 20, 2014 - Commentary
Getting it right when things go wrong.
Citation Text:
Pettker CM, Funai EF. Getting it right when things go wrong. JAMA. 2010;303(10):977-8. doi:10.1001/jama.2010.256.
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psnet.ahrq.gov/issue/checklist-manifesto-how-get-things-right
February 06, 2018 - Book/Report
Classic
The Checklist Manifesto: How to Get Things Right.
Citation Text:
The Checklist Manifesto: How to Get Things Right. Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.
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psnet.ahrq.gov/issue/thats-way-we-do-things-around-here
June 10, 2018 - Newspaper/Magazine Article
That’s the way we do things around here!
Citation Text:
That’s the way we do things around here! ISMP Medication Safety Alert! Acute care edition. February 24, 2011;16:1-2.
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psnet.ahrq.gov/node/33760/psn-pdf
February 01, 2014 - It's quite possible to be talking about one thing and looking
at a something different, to multitask … One thing that mitigates risk is how much of the primary task context is available when you resume it … You can just put your hand up or shake your head, "I'm on
the phone," that sort of thing. … The second thing you can do is to quickly note down the state of the world you're in, which might
be … For example, computer designers know that
it is a really bad thing to have an alert window pop up and
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psnet.ahrq.gov/node/74239/psn-pdf
January 12, 2022 - psnet.ahrq.gov/issue/high-risk-medications-hospitalized-elderly-adults-are-we-making-it-easy-do-wrong-thing
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psnet.ahrq.gov/node/838146/psn-pdf
September 21, 2022 - psnet.ahrq.gov/issue/diagnosis-ectopic-pregnancy
https://psnet.ahrq.gov/issue/my-whole-room-went-chaos-because-thing-corner-unintended-consequences-central-fetal