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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - Potential action plans
were already starting to be put into place when they thought events might be … you think that having something like this pandemic to rally around pushed leadership when it came
to thinking … Thinking about established patient safety practices
that you found that were misaligned, or where you … RD: I guess my final thought would be that I am humbled and impressed by the actions of healthcare
professionals
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psnet.ahrq.gov/node/33720/psn-pdf
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.
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psnet.ahrq.gov/node/33742/psn-pdf
December 01, 2012 - That was the conclusion, and I think he thought that was
it—that would take care of the problem. … We thought having it become a no pay
condition would be the absolute demise of delirium ever being recognized
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.110_slideshow.ppt
December 01, 2005 - pilots—nearly unanimously disagree with this statement; they would want to be questioned directly if coworker thought
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psnet.ahrq.gov/issue/guilty-afraid-and-alone-struggling-medical-error
July 01, 2020 - Commentary
Classic
Guilty, afraid, and alone — struggling with medical error.
Citation Text:
Delbanco T, Bell SK. Guilty, afraid, and alone--struggling with medical error. N Engl J Med. 2007;357(17):1682-3.
Copy Citation
Format:
Google Scholar PubM…
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psnet.ahrq.gov/node/33829/psn-pdf
March 01, 2017 - the whole group additional information that
would be helpful, insights they noticed, and what they thought
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psnet.ahrq.gov/node/49777/psn-pdf
December 01, 2016 - https://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 … 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/33785/psn-pdf
May 01, 2015 - We'd spent a long time thinking about
components of perioperative care—the use of antibiotics, the use … None of the surgeons that agreed to
participate in this study went into this study thinking that they … code and realized that they were in some ways staggeringly associated
with outcomes, what was your thought … I
thought that somehow that there was some tautology or other error associated with how the analysis … I'm thinking about the military or aviation
where they have done some aptitude testing before people
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psnet.ahrq.gov/node/49828/psn-pdf
May 01, 2018 - Out of Sight, Out of Mind: Out-of-Office Test Result
Management
May 1, 2018
Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
Case Objectives
Recognize the general responsibilities of…
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psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
January 01, 2015 - In the Lean philosophy, the first thought is to look at the system and processes, unless you can absolutely … I worry when I talk to an organization that is now embracing Lean, and their thought process is often … But that is archaic thinking." … Applying better thinking to the daily practice for anesthesiologists, Dr. … process improvement workshops (multidisciplinary improvement team efforts) helped turn these creative thoughts
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psnet.ahrq.gov/node/33641/psn-pdf
November 01, 2006 - concepts of human factors engineering, since these are an
antidote to the "expected complication" way of thinking … psnet.ahrq.gov//#ref3
https://psnet.ahrq.gov//#ref4
https://psnet.ahrq.gov//#ref5
What solutions were you thinking … In the central line case, perhaps you
thought that the nurse should have warned the physician before … Perhaps the
surprise would lead to all kinds of new thinking regarding how to match the design more
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psnet.ahrq.gov/issue/transition-planning-senior-surgeon-guidance-and-recommendations-society-surgical-chairs
August 14, 2019 - Commentary
Transition planning for the senior surgeon: guidance and recommendations from the Society of Surgical Chairs.
Citation Text:
Rosengart TK, Doherty G, Higgins R, et al. Transition Planning for the Senior Surgeon: Guidance and Recommendations From the Society of Surgical Chairs.…
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psnet.ahrq.gov/issue/proposed-approach-allegations-sexual-boundary-violation-health-care
October 19, 2022 - Study
A proposed approach to allegations of sexual boundary violation in health care.
Citation Text:
Cooper WO, Foster JJ, Hickson GB, et al. A proposed approach to allegations of sexual boundary violation in health care. Jt Comm J Qual Patient Saf. 2023;49(12):671-679. doi:10.1016/j.jcj…
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psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
February 26, 2025 - What other thoughts do you have on that? … What are your thoughts on how to address that? David Bates: I would ask them to report on less. … instrumental in radically reducing CLABSI note that at the time of To Err Is Human , CLABSIs were thought … in science and systemic investment in improving patient safety combined to make a complication, once thought
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psnet.ahrq.gov/perspective/are-we-safer-today
February 26, 2025 - instrumental in radically reducing CLABSI note that at the time of To Err Is Human , CLABSIs were thought … in science and systemic investment in improving patient safety combined to make a complication, once thought … What other thoughts do you have on that? … What are your thoughts on how to address that? David Bates: I would ask them to report on less.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - reside in recognizing what we are powerless to change
When can we challenge social arrangements once thought
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psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
August 28, 2024 - We believe we have a moral imperative to be open-minded to all the different possible approaches to thinking … Safety-II stresses critical thinking and what it takes to be agile and to adapt to different circumstances … We could have gone back to basics and doubled down on the traditional way of thinking about safety. … Chalapathy Venkatesan: When I first started to learn about Safety-I and Safety-II, I thought we do Safety-II … Leaders sometimes tend to filter and say, “But that's not how we do it” or “I thought we said this is
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psnet.ahrq.gov/node/33754/psn-pdf
September 01, 2013 - And that led to fascinating divergences between what the pilots thought they told the
airplane to do … When I've talked about and thought about just culture I've never heard it framed
that way—that we're … And your thinking about it actually seems to be
much more informed by almost Rawlsian principles of … just culture algorithms or mechanisms has grown on the back of the gradual acceptance of
systems thinking … We have systems thinking on the one hand: If you want to understand why things go
wrong you've got to
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psnet.ahrq.gov/node/33700/psn-pdf
October 01, 2010 - We asked him to speak with us about checklists and
other thoughts about the science of improving patient … I
actually thought we were on the same team, that it was the patient's team."
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psnet.ahrq.gov/node/33631/psn-pdf
April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to
Promote a Culture of Safety
April 1, 2006
Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a
Culture of Safety. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…