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psnet.ahrq.gov/node/35786/psn-pdf
May 07, 2007 - When Things Go Wrong: Responding to Adverse Events.
May 7, 2007
Boston, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
https://psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events
This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk manage…
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psnet.ahrq.gov/node/33736/psn-pdf
September 01, 2012 - That was one thing that
contributed to the calls in the mid to late 1990s for more study of patient
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psnet.ahrq.gov/issue/alarm-management-first-things-first-using-reliable-data-eliminate-unnecessary-alarms
July 29, 2009 - Newspaper/Magazine Article
Alarm management: first things first: using reliable data to eliminate unnecessary alarms.
Citation Text:
Alarm management: first things first: using reliable data to eliminate unnecessary alarms. Vanderveen T. Patient Saf Qual Healthc. November/December 2014;1…
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psnet.ahrq.gov/node/44140/psn-pdf
July 15, 2015 - Openness and Honesty When Things Go Wrong: the
Professional Duty of Candour.
July 15, 2015
London, UK: General Medical Council and the Nursing and Midwifery Council; June 29, 2015.
https://psnet.ahrq.gov/issue/openness-and-honesty-when-things-go-wrong-professional-duty-candour
Open and honest discussion with patie…
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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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www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2024-hcbs-chartbook.pdf
January 01, 2024 - 2024 HCBS CAHPS Survey Database Chartbook
The CAHPS® Home and Community-
Based Services (HCBS) Survey
Database 2024 Chartbook
Authors:
Teresa Dodson, M.A.
Michael Corrothers
Joshua Rubin
Jack Vallentine
Naomi Yount, Ph.D.
Joann Sorra, Ph.D.
Dale Shaller, M.P.A.
Prepared by:
Westat
1600 Research Boulev…
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psnet.ahrq.gov/issue/improving-ambulatory-patient-safety-learning-last-decade-moving-ahead-next
November 15, 2018 - January 3, 2017
Making it easier to do the right thing: a modern communication QI agenda
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psnet.ahrq.gov/node/33637/psn-pdf
August 01, 2006 - That has been the most rewarding thing in my professional life? … But it's been obvious to me that there are other people who can do
that sort of thing better, not the … LL: I think the exciting thing is that people now talk about safety all the time, and they're gradually
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psnet.ahrq.gov/node/33801/psn-pdf
February 01, 2016 - 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/33807/psn-pdf
May 01, 2016 - The other thing is that clinicians want to find one size fits all. … That needs to be the next thing to be talked about.
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psnet.ahrq.gov/node/33863/psn-pdf
August 01, 2018 - The other thing that is absolutely fabulous is computer-guided surgery. … One thing I'm seeing with new
technology, I'll use robotic surgery as an example, is that the patients
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hospital/about/child_hcaps_measures_909.pdf
May 11, 2016 - Patient Experience Measures from the CAHPS® Child Hospital Survey
CAHPS® Child Hospital Survey and Instructions
Patient Experience Measures from the
CAHPS® Child Hospital Survey
Introduction........................................................................... 1
Types of Measures ...........................…
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psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
November 01, 2006 - Now anybody who designs anything has a problem of understanding the thing they're designing too well, … We have situations in which there are two different brands of a device, both of which do the same thing … The other thing is that we learn a lot by mistakes and errors that do not lead to harm. … So all of us in everyday life forget things, make mistakes, or occasionally do the wrong thing.
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psnet.ahrq.gov/node/34767/psn-pdf
November 28, 2018 - Why Things Bite Back: Technology and the Revenge of
Unintended Consequences.
November 28, 2018
Tenner E. New York, NY: Knopf; 1996. ISBN: 0679425632.
https://psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences
Tenner’s discussions of medical and nonmedical examples provide an e…
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psnet.ahrq.gov/node/33792/psn-pdf
September 01, 2015 - 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.
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psnet.ahrq.gov/issue/strengthening-medical-error-meme-pool
August 08, 2012 - October 11, 2016
Making it easier to do the right thing: a modern communication QI agenda
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psnet.ahrq.gov/issue/health-literacy-and-communication-quality-health-care-organizations
November 26, 2014 - January 3, 2017
Making it easier to do the right thing: a modern communication QI agenda
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psnet.ahrq.gov/node/33662/psn-pdf
January 01, 2008 - We all know that that's the right thing to do, but concomitantly they've seen
a dramatic decrease in
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psnet.ahrq.gov/node/33833/psn-pdf
May 01, 2017 - But if a patient like that comes into my care, the easiest thing you
can do is just to keep them on … But the right thing to do is to have a difficult conversation. … Going up to 80 or 100
or 200 is the wrong thing to do, although we did it quite a lot. … So when we have people on high-dose opioids like this, the wrong thing to do is to cut their doses off
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2023-child-hcahps-chartbook.pdf
January 01, 2023 - Providers told parent how to report mistakes
Helping Your Child Feel Comfortable
Providers asked about thing