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Total Results: 2,437 records

Showing results for "thinking".

2181. 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

2182. Did We Forget Something? | PSNet
      psnet.ahrq.gov/web-mm/did-we-forget-something
      April 28, 2021 - January 4, 2024 Thinking in three's: changing surgical patient safety practices

2183. 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

2184. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport | PSNet
      psnet.ahrq.gov/web-mm/misplaced-vial-medication-kit-variability-contributes-medication-error-during-patient
      March 12, 2021 - October 1, 2004 Perspective Innovation and Lean Thinking

2185. Transition to Nowhere | PSNet
      psnet.ahrq.gov/web-mm/transition-nowhere
      March 21, 2009 - 2003 Perspective Establishing a Safety Culture: Thinking

2186. 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

2187. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? | PSNet
      psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
      June 24, 2020 - Dekker, PhD Professor and Director Leonardo da Vinci Laboratory for Complexity and Systems Thinking

2188. 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.…

2189. 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…

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. 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

2193. 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

2194. 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

2195. 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

2196. 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

2197. 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

2198. 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

2199. 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

2200. 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