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psnet.ahrq.gov/node/33674/psn-pdf
February 01, 2009 - We can prevent this really bad thing
from happening, which, when it happens, is harmful and often costs … So the idea of a policy that creates
skin in the game for hospitals to do the right thing and promotes … Do you think we're going to see more conditions added,
some of them removed, or the whole thing implode … 10 years is that trying to educate each of the 1000 physicians or 5000 nurses to each do the right
thing … Do you think this is a good thing?
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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/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/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/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/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/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/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/perspective/patient-advocacy-patient-safety-have-things-changed
June 01, 2014 - manager's office and was schooled about how it is vital that, at a daily newspaper, there's no such thing … The best thing is, again, when we all act as a partnership—when the clinicians, patients, and families … Then he tells the patient, "Just one thing: if we succeed and you survive, you must drive carefully
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psnet.ahrq.gov/taxonomy/term/3475
June 09, 2025 - Error
An act of commission (doing something wrong) or omission (failing to do the right thing) that
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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/50614/psn-pdf
October 30, 2019 - RW: You said one thing that was important was that the complications and hazards had been
underappreciated … Another thing we recognized when we published this paper (which was close to 50 pages long) was that … in different circumstances to scaling that and making sure that people are
always doing the right thing … We have tackled culture by making the right thing to do the easy thing to do. … It makes the right thing to do the
easy thing to do.
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psnet.ahrq.gov/issue/when-things-go-wrong-voices-patients-and-families
November 19, 2015 - Audiovisual
When Things Go Wrong: Voices of Patients and Families.
Citation Text:
When Things Go Wrong: Voices of Patients and Families. CRICO/RMF; Harvard Risk Management Foundation
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psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events
November 19, 2014 - Book/Report
Classic
When Things Go Wrong: Responding to Adverse Events.
Citation Text:
When Things Go Wrong: Responding to Adverse Events. Boston, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
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