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psnet.ahrq.gov/node/867986/psn-pdf
March 24, 2025 - For example,
people may admit to having had thoughts of killing themselves in the past two weeks, or … In the past, health systems thought that they only needed to keep people protected while
the person … If the person is positive on “thoughts of killing themselves” or “a recent
suicide attempt,” there are … For example, if they have intent to act on their suicidal
thoughts. … A person can have thoughts of killing themselves but say that they never intended to act on them.
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psnet.ahrq.gov/issue/effectiveness-using-simulation-development-clinical-reasoning-undergraduate-nursing-students
September 09, 2020 - systematic review found that repeated simulation exposures can lead to gains in clinical reasoning and critical … thinking.
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psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defining-clinical-reasoning
June 26, 2019 - The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking … March 8, 2017
Not thinking clearly? Play a game, seriously!
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psnet.ahrq.gov/issue/patient-safety-and-workplace-bullying-integrative-review
March 11, 2020 - and evaluation of a 3-day patient safety curriculum to advance knowledge, self-efficacy and system thinking … March 6, 2019
Systems thinking and incivility in nursing practice: an integrative review
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psnet.ahrq.gov/issue/simulation-based-adverse-event-reporting-system-development-and-feasibility
July 08, 2020 - Citation
Related Resources From the Same Author(s)
Participation in a system-thinking … May 18, 2022
Participation in a system-thinking simulation experience changes adverse
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psnet.ahrq.gov/issue/state-science-evolving-perspectives-human-error
February 22, 2023 - June 1, 2022
Toward the translation of systems thinking methods in patient safety practice … Related Resources
Thematic reviews of patient safety incidents as a tool for systems thinking
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psnet.ahrq.gov/issue/innovative-teaching-situational-awareness
November 04, 2020 - November 4, 2020
Levels of reflective thinking and patient safety: an investigation of … February 10, 2015
Levels of reflective thinking and patient safety: an investigation
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psnet.ahrq.gov/issue/how-do-simulated-error-experiences-impact-attitudes-related-error-prevention
October 19, 2022 - December 21, 2014
View More
Related Resources
Assessing system thinking … July 29, 2020
Participation in a system-thinking simulation experience changes adverse
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psnet.ahrq.gov/issue/impact-restraint-management-bundle-restraint-use-intensive-care-unit
October 18, 2023 - March 13, 2024
A concept analysis of systems thinking. … October 12, 2009
Preventing catheter-related bloodstream infections: thinking outside
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psnet.ahrq.gov/issue/understanding-complexity-safety-critical-setting-systems-approach-medication-administration
February 01, 2023 - Related Resources From the Same Author(s)
Toward the translation of systems thinking … Towards a unified model of accident causation: refining and validating the systems thinking
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psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-registered-nurses-perspective
June 01, 2016 - The test is comprehensive and requires critical thinking. … How have you thought about teaching that and how have you thought about testing that as part of the certification … RW : When you and the other leaders began thinking about patient safety, the American health care system … How does that change the thinking about the content and the methods of both training and certification … Some of our early approaches we thought, "This is a good idea.
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psnet.ahrq.gov/node/33849/psn-pdf
January 01, 2018 - I thought the
electronic medical record would end that, and indeed it has. … The thought process has been squeezed out of electronic notes. … But I like that because my
fingers never get ahead of my thinking. … But you wonder how
deeply are they thinking about it. … Their thought is everything I need to know is
in the computer.
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psnet.ahrq.gov/issue/when-missing-zebra-can-land-you-court
August 12, 2015 - December 21, 2014
Thinking about our thinking as physicians.
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psnet.ahrq.gov/node/837784/psn-pdf
August 05, 2022 - I wonder if we could shift the conversation to
thinking about safety implications. … I wonder if you have thoughts of
what other factors are potentially contributing to patient safety issues … Ultimately, if we were thinking of apps being as
powerful as medications, we need to support end-user … So, we thought, what would happen if we reengineered the process of being discharged from the hospital … So, we thought, what if we do this
for patients who just come into the hospital with a heart attack,
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psnet.ahrq.gov/node/33589/psn-pdf
September 15, 2024 - Characteristics of High Reliability Organizations
High reliability organizations use systems thinking … This mindset is supported by five
characteristic ways of thinking: preoccupation with failure; reluctance … Reliability1,2,3,4
Characteristic Description
Preoccupation
With Failure
Everyone is aware of and thinking
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psnet.ahrq.gov/issue/lessons-americas-safest-hospitals
November 16, 2016 - November 16, 2016
Cognitive Errors and Diagnostic Mistakes: A Case-Based Guide to Critical … Thinking in Medicine.
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psnet.ahrq.gov/issue/how-professionals-make-decisions
July 06, 2011 - Thinking About Learning for Improvement in Health Care. … May 13, 2015
Considering human factors and developing systems-thinking behaviours to
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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - It became a passion for me – thinking about how we look at events and improving the way we handle them … Do we have a learning organization where we are thinking about improvement? … People are sometimes intimidated by the thought of changing their whole process, but you do not have … One is thinking about the emotional harm we are causing to patients as well as staff. … We also need to begin thinking about how it is being used in other care settings.
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - It became a passion for me – thinking about how we look at events and improving the way we handle them … Do we have a learning organization where we are thinking about improvement? … People are sometimes intimidated by the thought of changing their whole process, but you do not have … One is thinking about the emotional harm we are causing to patients as well as staff. … We also need to begin thinking about how it is being used in other care settings.
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - doses of naloxone may be necessary to provide
continued reversal.
27
IMPROVING PATIENT SAFETY:
THINKING … BEYOND OPIOIDS
28
Thinking Beyond Opioids (1)
• Not all discomfort and pain respond to opioids and … ice/heat,
elevation, and physical therapy can help ease the burden of post-operative
pain.
29
Thinking … Administration During Codes (1)
Naloxone Administration During Codes (2)
improving patient safety: �Thinking … Beyond Opioids
Thinking Beyond Opioids (1)
Thinking Beyond Opioids (2)
Take Home Points
Take-Home