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psnet.ahrq.gov/issue/when-order-sets-do-not-align-clinician-workflow-assessing-practice-patterns-electronic-health
March 24, 2019 - September 24, 2016
We thought we would be perfect: medication errors before and after
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psnet.ahrq.gov/issue/calm-storm-utilizing-situ-simulation-evaluate-preparedness-alternative-care-hospital-during
December 23, 2020 - COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought
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psnet.ahrq.gov/issue/recommendations-individualized-medical-treatment-and-common-adverse-events-management-lung
March 24, 2019 - COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought
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psnet.ahrq.gov/issue/team-debriefing-covid-19-pandemic-qualitative-study-hospital-wide-clinical-event-debriefing
June 08, 2022 - COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought
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psnet.ahrq.gov/issue/universal-and-serial-laboratory-testing-sars-cov-2-long-term-care-skilled-nursing-facility
November 16, 2022 - COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought
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psnet.ahrq.gov/issue/pain-management-best-practices-multispecialty-organizations-during-covid-19-pandemic-and
November 16, 2022 - COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought
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psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
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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psnet.ahrq.gov/primer/debriefing-clinical-learning
September 15, 2024 - Its goals are to discuss the actions and thought processes involved in a particular clinical situation … from post-mission analysis of military or police actions and grew to include use in critical incidents thought … professionals. 4 Debriefing has now been widely adopted in the simulation and education fields and is thought … during this phase, and moderators may need to actively facilitate team members sharing what they were thinking … debriefing is designed to identify and summarize the main learning points, connect them with real-world thinking
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psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd
February 01, 2006 - At lunch, I said to this person, who I thought was a physician, "I have a hunch I didn't convince you … Patients and their family members absolutely will not tolerate thinking that their physician is being … We have shown these videos to volunteers and asked them what they thought about the discussions and the … I asked a woman what she thought of a vignette in which a surgeon is very slow to respond to urgent pages … She thought for a moment, and then responded, "He'd have to apologize and apologize, call me at home
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psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
February 01, 2006 - We have shown these videos to volunteers and asked them what they thought about the discussions and the … I asked a woman what she thought of a vignette in which a surgeon is very slow to respond to urgent pages … She thought for a moment, and then responded, "He'd have to apologize and apologize, call me at home … At lunch, I said to this person, who I thought was a physician, "I have a hunch I didn't convince you … Patients and their family members absolutely will not tolerate thinking that their physician is being
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psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
March 27, 2024 - Sarah Mossburg: I’m thinking back to the point you made earlier: that you can predict who’s at risk, … The clinician is looking at this patient thinking, “I don’t think so….” … We live in a pretty heterogeneous society, and the diversity of thought also conveys into the health … Sarah Mossburg: Do you have any thoughts around how models can be validated and monitored to ensure … Another consideration is that many of us thought that we’d be able to create a model, launch it into
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psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
March 27, 2024 - Sarah Mossburg: I’m thinking back to the point you made earlier: that you can predict who’s at risk, … The clinician is looking at this patient thinking, “I don’t think so….” … We live in a pretty heterogeneous society, and the diversity of thought also conveys into the health … Sarah Mossburg: Do you have any thoughts around how models can be validated and monitored to ensure … Another consideration is that many of us thought that we’d be able to create a model, launch it into
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psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
September 01, 2014 - The dreaded thought of missing a cancer diagnosis leads to overtesting. … give talks I ask two questions, have you or someone you know ever had medical care that you or they thought … or someone you know ever declined a treatment option recommended by a physician, because you or they thought … That tells me many people are thinking about this and being more involved in their medical decision-making … Then I asked him what he thought about these repeated tests after hearing the talk I had given, and he
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psnet.ahrq.gov/node/33869/psn-pdf
November 01, 2018 - I thought maybe I
could do an economic history of hospitalists. … DM: When I originally came up with the idea, I wasn't thinking about that per se. … I was thinking more about
whether care would be improved, and if we might lower the total cost of care … DM: When we started out, we thought about machine learning and did some predictive analytics looking … At the same time, our health system was thinking about becoming an accountable care
organization and
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psnet.ahrq.gov/node/37292/psn-pdf
May 24, 2015 - Guilty, afraid, and alone — struggling with medical error.
May 24, 2015
Delbanco T, Bell SK. Guilty, afraid, and alone--struggling with medical error. N Engl J Med.
2007;357(17):1682-3.
https://psnet.ahrq.gov/issue/guilty-afraid-and-alone-struggling-medical-error
Disclosure of medical errors remains an important a…
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psnet.ahrq.gov/perspective/conversation-shantanu-nundy-md
February 26, 2025 - So, I sat there thinking, this is a huge information problem because someone, somewhere knew what to … She had seen hundreds of doctors, and maybe some had been thinking about rheumatic causes of her fevers … even though she was stationed in Southeast Asia, and most of them thought infectious. … I was just thinking I'm going to put up a website and people are going to use it. … RW : As a computer science major jazzed about diagnostic errors, I would have thought the natural path
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psnet.ahrq.gov/issue/differentiating-between-detrimental-and-beneficial-interruptions-mixed-methods-study
May 03, 2017 - September 24, 2016
Momentary interruptions can derail the train of thought.
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psnet.ahrq.gov/issue/computerised-prescribing-safer-medication-ordering-still-work-progress
October 13, 2018 - December 21, 2017
We thought we would be perfect: medication errors before and after
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psnet.ahrq.gov/issue/physicians-failed-write-flawless-prescriptions-when-computerized-physician-order-entry-system
January 21, 2015 - November 11, 2015
We thought we would be perfect: medication errors before and after
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psnet.ahrq.gov/issue/patients-perspectives-quality-and-patient-safety-failures-lessons-learned-inquiry
September 28, 2017 - February 8, 2023
‘He thought what he was doing was good for people.’