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psnet.ahrq.gov/node/866216/psn-pdf
July 10, 2024 - Health Plan Patient Safety Initiatives
July 10, 2024
Helwig A, Sousane Z, Mossburg S. Health Plan Patient Safety Initiatives. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
When we think of improving patient safety, we often think of strategies that can be implemen…
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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…
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psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
May 01, 2014 - In Conversation With… Didier Pittet, MD, MS
May 1, 2014
Also Read an Essay
Citation Text:
In Conversation With… Didier Pittet, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. …
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psnet.ahrq.gov/perspective/acgmes-2017-revision-common-program-requirements
January 31, 2018 - June 10, 2020
Perspective
Establishing a Safety Culture: Thinking
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psnet.ahrq.gov/node/60376/psn-pdf
July 30, 2020 - Accessed May 2020
PSNet-Related Resources
Perspectives
Perspectives on Safety: New Thinking about
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psnet.ahrq.gov/web-mm/check-anesthesia-machine
August 01, 2006 - Or, perhaps an anesthesia technician turned it on when refilling it, erroneously thinking that the dial
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psnet.ahrq.gov/node/49817/psn-pdf
January 01, 2018 - and highlighted an opportunity for future
enhancement of the CPOE system to include human factors thinking
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psnet.ahrq.gov/web-mm/forgotten-med
July 01, 2006 - Therefore, thinking that the patient’s glycemic control had improved, he discontinued the QID glucose
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psnet.ahrq.gov/web-mm/refused-medication-error
November 01, 2005 - In thinking about this case, one can imagine an improved EHR that alerted team members of both the fact
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psnet.ahrq.gov/web-mm/feeling-no-pain
August 30, 2023 - in the center.( 9-11 ) In an effort to promote understanding among providers for whom systems-based thinking
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psnet.ahrq.gov/node/33618/psn-pdf
September 01, 2005 - paradigm for patient safety—moving away from individual
blame to a richer understanding of systems thinking
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - while ignoring others, akin to anchoring bias
• Learning tools teaching “outside-the-box” or “lateral” thinking
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psnet.ahrq.gov/node/49833/psn-pdf
June 01, 2018 - In thinking about this case, the communication among the nurse, ED physician, and the neurologist as
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psnet.ahrq.gov/web-mm/40-k
January 12, 2011 - 2015
Perspective
Establishing a Safety Culture: Thinking
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psnet.ahrq.gov/node/60330/psn-pdf
May 05, 2020 - addition to the more “traditional” uses of telehealth, the COVID-19 crisis has necessitated creative
thinking
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psnet.ahrq.gov/web-mm/do-me-favor
September 12, 2016 - objectivity on the part of patient or provider
Under- or over-treatment related to "wishful thinking
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psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
July 01, 2012 - Superficial thinking. AJR Am J Roentgenol. 2008;190:W318. [Available at] 9.
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psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - Patient safety in palliative care at the end of life from the perspective of complex thinking
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psnet.ahrq.gov/node/60722/psn-pdf
February 06, 2023 - 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 with
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psnet.ahrq.gov/node/49611/psn-pdf
October 01, 2010 - This schedule was thought to improve patient adherence, facilitate dosage adjustment, and permit more … to commit suicide,
patients with suicidal ideation will generally tell their physicians about such thoughts … drug cannot be tolerated or
produces no benefit; there are signs of severe depression with possible thought … disorder (e.g., psychosis,
disorganized thinking) or suicidal ideation; the patient is interested in