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psnet.ahrq.gov/issue/five-system-barriers-achieving-ultrasafe-health-care
September 29, 2017 - Commentary
Classic
Five system barriers to achieving ultrasafe health care.
Citation Text:
Amalberti R, Auroy Y, Berwick D, et al. Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005;142(9):756-64.
Copy Citation
Format:
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psnet.ahrq.gov/node/49624/psn-pdf
May 01, 2011 - The neurology and neurosurgical teams
thought that if the brain swelling had been recognized at the
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - SPOTLIGHT CASE
Out of Sight, Out of Mind: Out-of-Office Test Result Management
Citation Text:
Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
…
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - ://www.sprc.org/settings/primary-care/toolkit .( 11,12 ) Importantly, suicidal ideation (defined as thinking … If a patient expresses suicidal thoughts but the nature of the intent and plan is not clear, asking about … exposure (peer or celebrity) Access to lethal means Cognitive rigidity (perfectionistic, black or white thinking … Warning signs (thoughts, behaviors, situations) Internal coping mechanisms People/social settings that
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psnet.ahrq.gov/node/33689/psn-pdf
October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary,
Promoter of Patient Safety
October 1, 2009
Wachter R. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety. PSNet [internet].
2009.
https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
Perspective
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psnet.ahrq.gov/node/49812/psn-pdf
November 01, 2017 - Specimen Almost Lost
November 1, 2017
Hehe YK. Specimen Almost Lost. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/specimen-almost-lost
The Case
A 29-year-old woman presented to the hospital with a rash that had spread across her legs and abdomen.
She was admitted to the medicine service for further evalu…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
May 01, 2018 - Spotlight
Spotlight
Out of Sight, Out of Mind: Out-of-Office Test Result Management
1
Source and Credits
This presentation is based on the May 2018
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Eric Poon, MD, MPH, Duke University School o…
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psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp
October 30, 2019 - happens to a mom's preference about vaginal delivery versus C-section, from sitting in a prenatal visit thinking … I would have thought that all of the variables would be knowable, the size of the head, the contractility … Changing the "routine care" paradigm requires a cultural shift and a reorientation of thinking focused
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psnet.ahrq.gov/node/33796/psn-pdf
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.
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psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - There was no reason why the system architect should have thought to tell us or even annotate the system
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
June 01, 2005 - to treat acetaminophen overdoses and bronchitis.( 1 ) When I asked a nephrologist colleague what he thought
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psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
April 01, 2010 - What were you expecting to accomplish and what's worked the way you thought it would?
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psnet.ahrq.gov/node/60722/psn-pdf
February 06, 2023 - Biases in the Diagnostic Process
Clinician decision-making often relies on cognitive thought processes—called … It entails switching
from “automatic thinking” (also called “intuitive” or System 1 reasoning) to more … “reflective thinking” (also
called “analytical” or System 2 reasoning), informed by communication with
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psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
June 01, 2005 - to treat acetaminophen overdoses and bronchitis.( 1 ) When I asked a nephrologist colleague what he thought
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psnet.ahrq.gov/node/836976/psn-pdf
April 27, 2022 - IO lines focused on access through the sternum due to its high composition
of red marrow which was thought
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psnet.ahrq.gov/node/33768/psn-pdf
June 01, 2014 - Was that a choice on your part because that was what you thought had the
best chance to be successful … I learned that if
you understand structural thinking—if you understand feedback loops and the cultural … There are many
times when I want to smack someone on the side of the head and say, "What are you thinking
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psnet.ahrq.gov/issue/impact-ehealth-quality-and-safety-health-care-systematic-overview
December 14, 2016 - Review
The impact of eHealth on the quality and safety of health care: a systematic overview.
Citation Text:
Black AD, Car J, Pagliari C, et al. The impact of eHealth on the quality and safety of health care: a systematic overview. PLoS Med. 2011;8(1):e1000387. doi:10.1371/journal.pmed…
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psnet.ahrq.gov/issue/controversy-and-quality-improvement-lingering-questions-about-ethics-oversight-and-patient
January 15, 2014 - Commentary
Controversy and quality improvement: lingering questions about ethics, oversight, and patient safety research.
Citation Text:
Kass N, Pronovost P, Sugarman J, et al. Controversy and quality improvement: lingering questions about ethics, oversight, and patient safety research. …
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psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
June 01, 2004 - The neurology and neurosurgical teams thought that if the brain swelling had been recognized at the time
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psnet.ahrq.gov/node/33841/psn-pdf
September 01, 2017 - notes; and we had challenges deciphering individual
consultants' handwriting to know what they were thinking … That was a theme of
my research in thinking about this for a year: the unanticipated consequences of … various parties doing what
they thought was right.