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psnet.ahrq.gov/node/867653/psn-pdf
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/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - Gandhi : The way I see the National Patient Safety Foundation's role is to be a thought leader, to try … to push the thinking about where we need to go in patient safety to new areas, to expand our thoughts … Negotiating this new terrain is something we haven't fully thought through. … Do you have any thoughts about that?
TG : I agree. … But the thinking on it has broadened, so it's not just about that fear of punishment or blame; it's really
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www.ahrq.gov/teamstepps/instructor/fundamentals/module5/slsitmonitor.html
July 01, 2018 - The seal is thinking about eating the penguin, and the penguin is thinking about eating the fish. … Image: Four penguins all thinking about the same fish. … Membership
Lack of Time
Lack of Information Sharing
Hierarchy
Defensiveness
Conventional Thinking
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pbrn.ahrq.gov/talkingquality/resources/cognitive/index.html
September 01, 2019 - Cognitive testing is an interview method for investigating the thought processes and reactions that people … As the respondents look through the report, the interviewer prompts them to share their thoughts and … Listening as Respondent "Thinks Out Loud:" The interviewer asks respondents to share every thought and … opinion as they go through the document, a process known as "thinking out loud." … ask "Tell me what you are thinking" or "What are you thinking right now?"
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pcmh.ahrq.gov/talkingquality/resources/cognitive/index.html
September 01, 2019 - Cognitive testing is an interview method for investigating the thought processes and reactions that people … As the respondents look through the report, the interviewer prompts them to share their thoughts and … Listening as Respondent "Thinks Out Loud:" The interviewer asks respondents to share every thought and … opinion as they go through the document, a process known as "thinking out loud." … ask "Tell me what you are thinking" or "What are you thinking right now?"
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Johnson_90.pdf
June 10, 2008 - Systems thinking is the cornerstone of SBP. … Systems-based practice can be thought of as an analytic tool, as well as a way of viewing the
world, … Systems thinking is the cornerstone of how “learning organizations” think about their world.9
Learning … Systems thinking and the application of systems thinking through SBP
provide an opportunity to look … Acknowledgments
We thank the following people who agreed to be interviewed about their thoughts on Systems
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www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-cognitive-load.pdf
May 01, 2024 - diagnostic reasoning.5,6 Diagnostic reasoning is the process by which a clinician uses medical
knowledge, critical … Cognitive Load and Dual-Process Thinking
Cognitive load also directly impacts dual-process thinking. … If extrinsic load is low, both type 1 and type 2 thinking can occur. … A few thoughts on cognitive overload. … vignette-based as-
sessment under testing conditions designed to encourage either automatic or analytic thought
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effectivehealthcare.ahrq.gov/sites/default/files/lessons-transcript.pdf
January 06, 2017 - MOHR: That’s great and Pat you had some thoughts about this.
DR. … MOHR: Madeleine, I think you had some thoughts?
DR. … That’s just sort of the thoughts of how we’ve thought of it.
MS. MOHR: That’s great. … I’m thinking of
examples off the top of my head. … That’s my thoughts on it.
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effectivehealthcare-admin.ahrq.gov/sites/default/files/lessons-transcript.pdf
January 06, 2017 - MOHR: That’s great and Pat you had some thoughts about this.
DR. … MOHR: Madeleine, I think you had some thoughts?
DR. … That’s just sort of the thoughts of how we’ve thought of it.
MS. MOHR: That’s great. … I’m thinking of
examples off the top of my head. … That’s my thoughts on it.
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - So, it gets me thinking about the things we are doing together. … It also gets me thinking about
the things that might be nuisances in my everyday work. … But sometimes when I describe it that
way, I realize that people are not necessarily thinking about … , a set of
questions you ask whenever you’re thinking about something you might change or improve. … Are we making
sure we are thinking preemptively about what could go wrong?
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/cauti-surveillance/pocket-card.pptx
March 13, 2017 - (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from … in severity)
□ Inattention (difficulty focusing and cannot maintain attention)
□ Disorganized thinking … (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from … (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from … (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/cauti-surveillance/pocket-card.pptx
March 13, 2017 - (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from … in severity)
□ Inattention (difficulty focusing and cannot maintain attention)
□ Disorganized thinking … (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from … (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from … (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/cauti-surveillance/pocket-card.pptx
March 13, 2017 - (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from … in severity)
□ Inattention (difficulty focusing and cannot maintain attention)
□ Disorganized thinking … (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from … (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from … (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from
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psnet.ahrq.gov/issue/who-patient-safety-curriculum-guide-medical-schools
March 23, 2011 - August 3, 2022
Developing critical thinking skills for delivering optimal care
July
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psnet.ahrq.gov/issue/ncicle-pathways-excellence-expectations-optimal-clinical-learning-environment-achieve-safe
October 18, 2017 - February 23, 2022
Developing critical thinking skills for delivering optimal care
-
psnet.ahrq.gov/node/838222/psn-pdf
September 28, 2022 - We spent a lot of time thinking
about the four Cs of primary care: contact, continuity, comprehensiveness … You
spoke about some examples of high-quality care, and I’m wondering if you have any thoughts on ways … So now, we’ve been thinking about the four
Cs and how they relate to quality. … I’d like to
transition into discussing patient safety and thinking a little bit more about avoidance … We are always thinking about how to
ensure that anything we do for patients may help them and decrease
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effectivehealthcare.ahrq.gov/sites/default/files/hawley-presentation.pdf
November 11, 2015 -
When I thought … I just went online and found this one which I thought was
useful for us to have today because … we want to be thinking broadly and this is broad
definition of the things that make up a group … Pointing us to the thoughts that if
providers don't know these things before going into the … So if we're thinking about interventions to
improve engagement and share decision making, I
-
effectivehealthcare-admin.ahrq.gov/sites/default/files/hawley-presentation.pdf
November 11, 2015 -
When I thought … I just went online and found this one which I thought was
useful for us to have today because … we want to be thinking broadly and this is broad
definition of the things that make up a group … Pointing us to the thoughts that if
providers don't know these things before going into the … So if we're thinking about interventions to
improve engagement and share decision making, I
-
psnet.ahrq.gov/node/34759/psn-pdf
July 13, 2016 - almost nothing specifically on health care, clinical psychologist James Reason has
influenced modern thinking … less theoretical and may be more appropriate for the reader interested in an
introduction to Reason’s thinking
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psnet.ahrq.gov/node/43395/psn-pdf
July 30, 2014 - Emphasizing how differences between slow thinking and fast
thinking can cause interpretation errors,