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Total Results: 2,437 records

Showing results for "thinking".

2181. Building a Safety Program Using Principles of Resilience Engineering | PSNet
      psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
      October 23, 2013 - health care will require that we explore strategies to effectively integrate these concepts into safety thinking

2182. Workaround Error | PSNet
      psnet.ahrq.gov/web-mm/workaround-error
      October 30, 2024 - Even under the best circumstances, there are limits on human thinking and the ability to be consistently

2183. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-473
      March 25, 2025 - the importance of understanding failure to rescue, the patient’s role in care escalation, and systems thinking

2184. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49444/psn-pdf
      May 01, 2004 - Lack of objectivity on the part of patient or provider Under- or over-treatment related to "wishful thinking

2185. Don’t Bite Your Tongue. | PSNet
      psnet.ahrq.gov/web-mm/dont-bite-your-tongue
      September 18, 2024 - The safety journal: lessons learned with an error reporting tool to stimulate systems thinking

2186. Tough Call: Addressing Errors From Previous Providers | PSNet
      psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
      July 17, 2024 - Review how to balance systems thinking with individual accountability in health care. … I thought you would want know the final diagnosis."

2187. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error | PSNet
      psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
      July 30, 2020 - Biases in the Diagnostic Process Clinician decision-making often relies on cognitive thought processes—called … It entails switching from “automatic thinking” (also called “intuitive” or System 1 reasoning ) to more … “reflective thinking” (also called “analytical” or System 2 reasoning), informed by communication

2188. Do medical inpatients who report poor service quality experience more adverse events and medical errors? | PSNet
      psnet.ahrq.gov/issue/do-medical-inpatients-who-report-poor-service-quality-experience-more-adverse-events-and
      July 14, 2021 - Study Classic Do medical inpatients who report poor service quality experience more adverse events and medical errors? Citation Text: Taylor BB, Marcantonio ER, Pagovich O, et al. Do medical inpatients who report poor service quality experience more adverse ev…

2189. We want to know: eliciting hospitalized patients' perspectives on breakdowns in care. | PSNet
      psnet.ahrq.gov/issue/we-want-know-eliciting-hospitalized-patients-perspectives-breakdowns-care
      January 12, 2022 - Study We want to know: eliciting hospitalized patients' perspectives on breakdowns in care. Citation Text: Fisher K, Smith KM, Gallagher TH, et al. We want to know: eliciting hospitalized patients' perspectives on breakdowns in care. J Hosp Med. 2017;12(8):603-609. doi:10.12788/jhm.2783.…

2190. Engaging patients in medication reconciliation via a patient portal following hospital discharge. | PSNet
      psnet.ahrq.gov/issue/engaging-patients-medication-reconciliation-patient-portal-following-hospital-discharge
      February 03, 2011 - Study Engaging patients in medication reconciliation via a patient portal following hospital discharge. Citation Text: Heyworth L, Paquin AM, Clark J, et al. Engaging patients in medication reconciliation via a patient portal following hospital discharge. J Am Med Inform Assoc. 2014;21(e…

2191. Tackling ambulatory safety risks through patient engagement: what 10,000 patients and families say about safety-related knowledge, behaviors, and attitudes after reading visit notes. | PSNet
      psnet.ahrq.gov/issue/tackling-ambulatory-safety-risks-through-patient-engagement-what-10000-patients-and-families
      March 20, 2017 - Study Tackling ambulatory safety risks through patient engagement: what 10,000 patients and families say about safety-related knowledge, behaviors, and attitudes after reading visit notes. Citation Text: Bell SK, Folcarelli P, Fossa A, et al. Tackling Ambulatory Safety Risks Through Pati…

2192. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49573/psn-pdf
      January 01, 2009 - In some cases, this strategy could prove vitally important in supporting anticipatory thinking about

2193. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
      January 01, 2024 - Although both approaches to thinking about problem representation have utility, we will focus primarily … which all team members – including patients and their families – can contribute and view one another's thoughts

2194. Dropping the Ball Despite an Integrated EMR | PSNet
      psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
      January 07, 2015 - Presumably, the PA and ED physician, who did receive the notice, thought the PCP had also received the … I've already alluded, low accident rates or patient safety event rates may mislead or lull some into thinking

2195. Electronic Err | PSNet
      psnet.ahrq.gov/web-mm/electronic-err
      April 01, 2014 - The vendor thought that the latter solution could be implemented over a 6- to 12-month time frame. … December 1, 2005 Perspective Innovation and Lean Thinking

2196. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50389/psn-pdf
      September 25, 2019 - The major cause of the missed diagnosis of sepsis was thought to be the focus on tumor lysis syndrome … The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking

2197. The Missing Suction Tip | PSNet
      psnet.ahrq.gov/web-mm/missing-suction-tip
      January 01, 2006 - However, 88% of retained foreign bodies occurred in the setting of a final count that was mistakenly thought … understanding of an event and also help identify factors in the broader environment that influenced their thinking

2198. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49676/psn-pdf
      February 01, 2013 - As early as 2003, mortality from PCA use was thought to be a low likelihood event, ranging between 1 … Confirmation bias is a selective type of thinking whereby one tends to read or hear what they expect

2199. Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
      January 01, 2022 - technological or organizational barriers – Cognitive errors, which include inadequate knowledge, poor critical … thinking skills, a lack of competency, problems in data gathering, and failing to synthesize information

2200. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49863/psn-pdf
      May 01, 2019 - Good Catch in the Operating Room May 1, 2019 Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/good-catch-operating-room The Case A 46-year-old woman with extensive history of back pain from lumbar stenosis was scheduled for an elective laminectomy and spinal…