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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/perspective/conversation-david-w-bates-about-are-we-safer-today
February 26, 2025 - It is an obvious thing, although the definition can be tricky. … The first thing you have to figure out is if the diagnosis is wrong, and I think artificial intelligence
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psnet.ahrq.gov/perspective/are-we-safer-today
February 26, 2025 - It is an obvious thing, although the definition can be tricky. … The first thing you have to figure out is if the diagnosis is wrong, and I think artificial intelligence
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digital.ahrq.gov/2020-year-review/research-summary/young-heart-improving-hypertension-management-kids
January 01, 2020 - This tool is hopefully helping providers do the right 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/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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digital.ahrq.gov/ahrq-funded-projects/care-transitions-and-teamwork-pediatric-trauma-implications-health-information/citation/information
January 01, 2023 - Information flow during pediatric trauma care transitions: things falling through the cracks.
Citation
Hoonakker PLT, Wooldridge AR, Hose BZ, Carayon P, Eithun B, Brazelton TB 3rd, Kohler JE, Ross JC, Rusy DA, Dean SM, Kelly MM, Gurses AP. Information flow during pediatric trauma care transitions: th…
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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/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/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/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/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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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Tool_9_AdvisorTrain_508.docx
March 06, 2013 - Strategy 1: Working with Patients & Families as Advisors (Tool 9)
Patient and Family Advisor
Orientation Manual
Strategy 1: Working with Patients & Families as Advisors (Tool 9)
[Type text] [Type text] [Type text]
Strategy 1: Working With Patients & Families as Advisors (Tool 9)
Guide to Patient and Family Engagem…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Tool_9_AdvisorTrain_508.pdf
March 06, 2013 - Strategy 1: Working with Patients & Families as Advisors (Tool 9)
Guide to Patient and Family Engagement
Patient and Family Advisor
Orientation Manual
Guide to Patient and Family Engagement
Table of Contents
About This Orientation Manual ..........................................................…
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psnet.ahrq.gov/issue/patients-use-internet-technology-report-when-things-go-wrong
July 21, 2009 - Study
Patients use an internet technology to report when things go wrong.
Citation Text:
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.
Copy Citation
Format:
Google Scholar PubMe…
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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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effectivehealthcare.ahrq.gov/sites/default/files/fagerlin-presentation.pdf
May 29, 2025 - work that I’ve done, people will say, for example, with
breast cancer, that the
most important thing … So, for example, in prostate cancer, somebody might say, “The most
important thing for me is not to … when
the information is presented in relative versus absolutely risk conditions.
12
Another thing
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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/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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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hospital/about/measures-child-hcahps-909.pdf
March 20, 2017 - Patient Experience Measures from the CAHPS® Child Hospital Survey
CAHPS® Child Hospital Survey and Instructions
Patient Experience Measures from the CAHPS Child Hospital Survey
Document No. 909
Updated 3/20/17
Patient Experience Measures from the
CAHPS® Child Hospital Survey
Introduction..................…