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psnet.ahrq.gov/issue/catching-and-correcting-near-misses-collective-vigilance-and-individual-accountability-trade
March 24, 2012 - August 10, 2011
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He thought the "lady
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psnet.ahrq.gov/issue/espen-guideline-hospital-nutrition
February 17, 2015 - COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought
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psnet.ahrq.gov/issue/how-should-us-hospitals-prepare-coronavirus-disease-2019-covid-19
June 14, 2017 - COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought
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psnet.ahrq.gov/issue/quality-safety-time-coronavirus-design-better-learn-faster
March 29, 2017 - COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought
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psnet.ahrq.gov/issue/shifting-learning-curve
March 09, 2009 - Resources
COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought
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psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
February 26, 2025 - It's also the rate by which technological solutions have been adopted in health care—I'm particularly thinking … scandal here in Denmark, was that the health care management purchased a very expensive system and thought … The basic idea is that even when something goes wrong, people were trying to do what they thought was … You have to spend time now thinking about what you're going to do later, otherwise you won't be able … I'm still not pessimistic, but what I'm worried about is that people do not spend enough time thinking
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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/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/situ-simulation-strategy-restore-patient-safety-intensive-care-units-after-covid-19-pandemic
March 09, 2022 - COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought
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psnet.ahrq.gov/issue/hospital-wide-cardiac-arrest-situ-simulation-identify-and-mitigate-latent-safety-threats
April 14, 2021 - COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought
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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/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/issue/covid-19-hospital-outbreaks-protecting-healthcare-workers-protect-frail-patients-italian
March 18, 2020 - COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought
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psnet.ahrq.gov/issue/effectiveness-improving-healthcare-teams-human-factor-skills-using-simulation-based-training
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/web-mm/misread-label
August 28, 2024 - If whoever administered the drug confused naloxone with Lanoxin, either because she thought this was … Packaging and look-alike/sound-alike drugs are thought to be important contributing factors.
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psnet.ahrq.gov/node/34868/psn-pdf
February 03, 2011 - Role of computerized physician order entry systems in
facilitating medication errors.
February 3, 2011
Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating
medication errors. JAMA. 2005;293(10):1197-203.
https://psnet.ahrq.gov/issue/role-computerized-physician-ord…
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psnet.ahrq.gov/node/50931/psn-pdf
February 26, 2020 - Mindful recognition of how physicians think and the ways in which their thinking fails (meta-
cognition … a multidisciplinary provider team may warrant strategies
specifically to promote slower “analytic” thought … over quicker “intuitive” thinking.7 For example, daily
multidisciplinary ICU rounds is a well-accepted
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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - polymorphic ventricular tachycardia that has a characteristic appearance on electrocardiograms and is thought … Any offending medications that are thought to be the cause of or contributing to the prolongation of … Patients who present with diabetic ketoacidosis are typically thought to have a total body deficiency
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psnet.ahrq.gov/node/49787/psn-pdf
March 01, 2017 - widely across medical specialties, but it is clear that
they are more common and more costly than first thought … multifactorial, highly subjective, imprecise, and difficult to analyze without
understanding the clinician's thought … to improve conditions for thinking all have potential to reduce diagnostic errors, and
they require … about your thinking"
Cognitive forcing strategies
Structured reflection
"Two-pass" diagnostic approach … Understanding how systems affect thinking
Recognizing and compensating for system flaws
Openness
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psnet.ahrq.gov/issue/time-transparent-standards-quality-reporting-health-care-organizations
July 07, 2021 - January 1, 2004
Patient safety reporting: a qualitative study of thoughts and perceptions