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psnet.ahrq.gov/node/33845/psn-pdf
November 01, 2017 - WP: Thinking about it from a patient's perspective, the primary role of my work, a lot of systems that … Another perspective was thinking about
the hospital environment for caregivers, particularly parents … They have a whole life, so thinking about
how that connects to the rest of their life is also really … RW: When you talked about the needs of patients in the beginning, were you thinking about peer-to-peer … WP: When I first got started, I definitely wasn't thinking about peer-to-peer information exchange.
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psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
February 01, 2012 - Robert Wachter, Editor, AHRQ WebM&M : As you thought about the way residents were supervised when you … group of residents who do the work but intellectually don't feel on the line and responsible for the thinking … hospital creating a job description for the hospitalists that serves a set of needs that no one even thought … technology of residency training, because the residents are not necessarily in the right place to learn critical … thinking in their field.
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psnet.ahrq.gov/node/73906/psn-pdf
October 06, 2021 - I'm an anthropologist
by training, and to me that means really thinking about human needs and applying … In thinking about safety,
that becomes really important. … KH: So, that's really interesting, and when thinking about redesigning care, where do you even start? … that this is important and that it's important to take care of
women once the baby is out and really thinking … We thought implementing a standard set of postpartum pain orders
would help, but it hasn’t changed at
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psnet.ahrq.gov/perspective/suicide-prevention
March 24, 2025 - In the past, health systems thought that they only needed to keep people protected while the person was … Sarah Mossburg : That is a helpful outline for folks in the field who are thinking about where they are … For example, if they have intent to act on their suicidal thoughts. … Sarah Mossburg : Thinking back to the incidental appearance of suicide risk for people who are being … Edwin Boudreaux : When we are thinking of high-quality suicide-related care, we often get bogged down
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psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention
March 25, 2025 - In the past, health systems thought that they only needed to keep people protected while the person was … Sarah Mossburg : That is a helpful outline for folks in the field who are thinking about where they are … For example, if they have intent to act on their suicidal thoughts. … Sarah Mossburg : Thinking back to the incidental appearance of suicide risk for people who are being … Edwin Boudreaux : When we are thinking of high-quality suicide-related care, we often get bogged down
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psnet.ahrq.gov/perspective/conversation-lucian-leape-md
June 12, 2019 - When I first looked at it, I thought there must be something wrong with this study. … Because I'm sure in Canada they thought they were doing a good thing.
LL : Exactly. … It will be more costly than we thought because of the kinds of changes that are needed. … And we were pretty naÏve in thinking that (a) they would believe us, and (b) that they could make those … If we'd have been a little smarter about thinking about what the culture changes would be and what would
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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/issue/cognitive-informatics-reengineering-clinical-workflow-safer-and-more-efficient-care
July 13, 2011 - August 2, 2016
Cognitive Errors and Diagnostic Mistakes: A Case-Based Guide to Critical … Thinking in Medicine.
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psnet.ahrq.gov/issue/teaching-medication-reconciliation-through-simulation-patient-safety-initiative-second-year
May 04, 2010 - May 3, 2023
Assessing system thinking in senior pharmacy students using the innovative … February 23, 2022
Participation in a system-thinking simulation experience changes adverse
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psnet.ahrq.gov/issue/misreading-injectable-medications-causes-and-solutions-integrative-literature-review
May 04, 2010 - Resources
Towards a unified model of accident causation: refining and validating the systems thinking … February 22, 2023
Toward the translation of systems thinking methods in patient safety
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psnet.ahrq.gov/issue/patient-safety-objective-structured-clinical-examination
October 06, 2011 - The safety journal: lessons learned with an error reporting tool to stimulate systems thinking … The safety journal: lessons learned with an error reporting tool to stimulate systems thinking
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psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph
December 21, 2022 - RW: When did you begin thinking that no-fault might be a better way to deal with medical injury? … argument was that only by getting rid of the moral blameworthiness part of medical malpractice and thinking … RW: In medical thinking about the issue of patient safety, we've sort of gone from it's all about the … , and plaintiff's attorneys—are all now aware that there's a lot more injury in hospitals than they thought … There's no executive in health care today who is thinking, "I can really reduce my malpractice costs
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psnet.ahrq.gov/node/33826/psn-pdf
February 01, 2017 - We spoke with her about
new thinking about teamwork.
Dr. Robert M. … I have some thoughts about how we might get started, and your expertise is going to be
invaluable. … As we've thought about other industries, a big part of
the solution is thinking about systems rather … First, the challenges we were just
discussing were bad enough, when we thought that we did our best … We
need to be thinking carefully about technology.
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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/866622/psn-pdf
August 28, 2024 - believe we have a moral imperative to be open-
minded to all the different possible approaches to thinking … Safety-II stresses
critical thinking and what it takes to be agile and to adapt to different circumstances … We could have gone back to basics and doubled down on the traditional
way of thinking about safety. … Chalapathy Venkatesan: When I first started to learn about Safety-I and Safety-II, I thought we do Safety … Leaders sometimes tend to filter and say, “But that's not how we do it” or “I thought we said this is
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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/balancing-supervision-and-autonomy-ongoing-tension
February 01, 2012 - Robert Wachter, Editor, AHRQ WebM&M : As you thought about the way residents were supervised when you … group of residents who do the work but intellectually don't feel on the line and responsible for the thinking … hospital creating a job description for the hospitalists that serves a set of needs that no one even thought … technology of residency training, because the residents are not necessarily in the right place to learn critical … thinking in their field.
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psnet.ahrq.gov/issue/patient-assisted-incident-reporting-including-patient-patient-safety
June 16, 2011 - November 10, 2010
Patient safety reporting: a qualitative study of thoughts and perceptions … and evaluation of a 3-day patient safety curriculum to advance knowledge, self-efficacy and system thinking
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psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
August 01, 2006 - And then, based on that I thought, we have to see if we can prove this in practice. … RW: I imagine that it's hard for people to hold these thoughts in one brainthat it's mostly about systems … Do you worry about it, to some extent, undermining the message about systems thinking? … I just think it's another set of issues to which we must apply similar thinking. … The ideas of systems thinking and the importance of human factors are now more generally appreciated.
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psnet.ahrq.gov/node/33710/psn-pdf
May 01, 2011 - How much linkage was there in your thinking about this concept of the second
victim and the main theme … AW: I had been thinking about this issue for a few years. … In fact, I began thinking about it when you and I
were RWJ Fellows in San Francisco and I did a study … She meant that she had an incident that she thought she
should tell me about but couldn't bring herself … RW: You mentioned that you thought the no blame approach was somewhat helpful in terms of mitigating