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Total Results: 2,562 records

Showing results for "thinking".

281. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60173/psn-pdf
     March 30, 2020 - The lens that I believe I brought to the panel was how the end-users are thinking about patient safety … I thought that was very helpful. … Thinking back to “To Err is Human,” one of the big things it talked about was creating a patient safety … We thought that was going to be the answer, but later figured out it was not the best approach. … For example, with regards to retained foreign bodies and wrong site surgeries, I remember thinking when

282. A patient safety objective structured clinical examination. | PSNet
     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

283. Misreading injectable medications—causes and solutions: an integrative literature review. | PSNet
     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

284. Teaching medication reconciliation through simulation: a patient safety initiative for second year medical students. | PSNet
     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

285. In Conversation With… Paul G. Shekelle, MD, MPH, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd
     February 26, 2025 - community about the kinds of contextual issues that might be important, there also was not a lot of thinking … analogy to age, gender, New York Heart Association classification, presence of diabetes, etc., when thinking … whether you do it or not might be publicly reported, but it would never be (at least in the present thinking … It's not clear exactly how independent these three are, but all of them in some form or another are thought … So measuring something in those four domains and reporting on it was thought to be an important factor

286. Psn-Pdf (pdf file)
     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

287. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867696/psn-pdf
     March 05, 2025 - importance of understanding failure to rescue, the patient’s role in care escalation, and systems thinking

288. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866358/psn-pdf
     July 24, 2024 - issue/error-medicine https://psnet.ahrq.gov/issue/does-concept-safety-culture-help-or-hinder-systems-thinking-safety

289. In Conversation With… Mark L. Graber, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
     January 01, 2016 - Our Society [SIDM] thought if we could convince the IOM to undertake a major report on diagnostic error … Where did that come out in the committee's deliberations, and what are your thoughts about that? … This is where we document our thoughts, find our information, and communicate with others. … interventions are rigorously evaluated.( 14,15 ) Our work ahead should also define how to maintain our critical … thinking skills, particularly in an environment of increasingly complex and automated technologies.(

290. The Evolution of Root Cause Analysis | PSNet
     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.

291. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet
     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.

292. Cognitive Informatics: Reengineering Clinical Workflow for Safer and More Efficient Care. | PSNet
     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.

293. In Conversation With… Lucian Leape, MD | PSNet
     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

294. Psn-Pdf (pdf file)
     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.

295. Lesson from the VA's Team Training Program | PSNet
     psnet.ahrq.gov/perspective/lesson-vas-team-training-program
     November 01, 2011 - Eduardo Salas : Well, I thought I would find that health care and medicine in general understand the … Always thinking about what you're thinking. Again, in the military we did that with simulations. … RW : It sounds like it begins with thinking about your own thinking. … RW : I hadn't really thought about this notion that the signal for me to think carefully about this and … We have to start thinking about human–system integration.

296. In Conversation With… Lawrence Smith, MD | PSNet
     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.

297. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73450/psn-pdf
     June 30, 2021 - clinical reasoning in the emergency department and shares tactics that minimize their potential impact on thinking

298. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47412/psn-pdf
     October 31, 2018 - The author explores the role of clinical teams in applying systems thinking to reduce blame, improve

299. In Conversation with…Pat Croskerry, MD, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
     June 01, 2010 - I started seeing these repeated thinking errors that very hard-working people were making. … I want to emphasize that I don't think anybody was being casual or sloppy in their thinking. … In the end, I decided to spend my time thinking about how doctors think. … brain of Pat Croskerry when a patient with chest pain comes to see you, versus a physician who hasn't thought … Say what you were thinking; say what you think you were doing wrong.

300. Psn-Pdf (pdf file)
     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