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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/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/issue/advances-human-factors-and-ergonomics-healthcare-and-medical-devices
August 28, 2019 - August 28, 2019
Cognitive Errors and Diagnostic Mistakes: A Case-Based Guide to Critical … Thinking in Medicine.
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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/issue/how-series-errors-led-recurrent-hypoglycemia
April 23, 2014 - The safety journal: lessons learned with an error reporting tool to stimulate systems thinking … July 2, 2019
Use of design thinking and human factors approach to improve situation awareness
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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/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/high-fidelity-simulations-impact-clinical-reasoning-and-patient-safety-scoping-review
January 26, 2022 - December 1, 2021
Participation in a system-thinking simulation experience changes adverse … February 27, 2019
Levels of reflective thinking and patient safety: an investigation
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psnet.ahrq.gov/issue/impact-power-health-care-team-performance-and-patient-safety-review-literature
February 01, 2023 - Related Resources From the Same Author(s)
Toward the translation of systems thinking … Resources
Towards a unified model of accident causation: refining and validating the systems thinking
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psnet.ahrq.gov/node/35018/psn-pdf
November 28, 2018 - implementing
this approach, which calls for leaders to facilitate a group process and to encourage innovative thinking
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psnet.ahrq.gov/node/44503/psn-pdf
November 18, 2024 - cover key patient safety concepts to enhance
participants' knowledge about safety culture, systems thinking
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
March 27, 2024 - My recollection is that a memo you wrote got people to begin thinking about federal engagement and trying … We were thinking, for example, about what innovative future NIH [National Institutes of Health] grants … never have happened without Meaningful Use requirements because doctors and hospitals just haven't been thinking … I'm going to call out things that did not exist 10 years ago and do now, and I'd love to hear your thoughts … I thought if you could do this around the United States, can you imagine how much unnecessary imaging
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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
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psnet.ahrq.gov/issue/flaws-clinical-reasoning-common-cause-diagnostic-error
September 30, 2012 - Patient safety in palliative care at the end of life from the perspective of complex thinking … November 4, 2014
The ethical imperative to think about thinking.
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psnet.ahrq.gov/issue/human-factors-engineering-its-place-and-potential-or-safety
May 24, 2017 - Related Resources From the Same Author(s)
Applying human-centered design thinking … June 12, 2019
Applying human-centered design thinking to enhance safety in the OR.
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psnet.ahrq.gov/issue/evaluating-situation-awareness-integrative-review
January 01, 2016 - Patient safety in palliative care at the end of life from the perspective of complex thinking … August 21, 2019
Systems thinking and incivility in nursing practice: an integrative review
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psnet.ahrq.gov/node/33644/psn-pdf
December 01, 2006 - Establishing a Safety Culture: Thinking Small
December 1, 2006
Hoff TJ. … Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006. … https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
Perspective
Safety cultures … concept as if it has universality in both
https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small … Self-reflection, empathy, inquiry,
feedback, forgiveness, systems thinking, communication, and creative
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - David Bates: I'd have to say that things have gone slower than I thought they might. … That being said, I think physicians for the foreseeable future are going to continue to do the
thinking … RW: If a hospital was thinking about getting into IT and could buy only one thing or needed to figure … Some of the things that I
thought would be really straightforward and would work really well didn't … We're thinking of trying to
develop a single in-basket so that all the things that come in that you
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psnet.ahrq.gov/issue/concealed-renal-insufficiency-and-adverse-drug-reactions-elderly-hospitalized-patients
March 27, 2024 - April 7, 2021
Choosing wisely in clinical practice: embracing critical thinking, striving
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psnet.ahrq.gov/node/60691/psn-pdf
July 15, 2020 - mixed-methods-systematic-review-interventions-address-incivility-nursing
https://psnet.ahrq.gov/issue/systems-thinking-and-incivility-nursing-practice-integrative-review