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psnet.ahrq.gov/issue/covid-19-reminder-reason
October 24, 2018 - April 29, 2020
For 4 days, the hospital thought he had just pneumonia.
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psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems-months-shutdown-then
July 18, 2018 - September 28, 2022
‘He thought what he was doing was good for people.’
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psnet.ahrq.gov/issue/mea-culpa-childrens-was-confident-its-air-systems-werent-source-infection
July 19, 2010 - August 24, 2022
‘He thought what he was doing was good for people.’
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digital.ahrq.gov/sites/default/files/docs/technologies-underserved-populations-slides-02282023.pdf
February 28, 2023 - Discrimination and Resilience
• Family Planning
• Adverse Childhood Events / IPV
• Violence
61
Final Thoughts … Final Thoughts
Contact Information
Interpreting Language in Medical and Psychiatric Consultations:
-
www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-16-academic-detailing.pdf
September 01, 2015 - The challenge with a stall is that it keeps you from knowing the clinician’s true
thinking.
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effectivehealthcare.ahrq.gov/sites/default/files/obesity-horizon-scan-high-impact-1306.pdf
July 01, 2013 - Development of obesity was at one time thought to be simply a product of caloric intake that
exceeded … Key Expert Comments: Overall, experts thought that ReShape Duo has potential to fulfill a
large … Experts thought that liraglutide’s
availability for treating obesity might reduce hospitalizations … Key Expert Comments: Experts thought that available clinical data indicated lorcaserin
seemed … Experts thought
that available clinical trial data was promising regarding liraglutide’s ability to
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psnet.ahrq.gov/perspective/conversation-dave-debronkart
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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www.ahrq.gov/healthsystemsresearch/hspc-research-study/overlap-and-coordination.html
June 01, 2020 - We thought that they worked together on solving problems, but we basically brought them together and … applications for funding between AHRQ and NIH, such as a study where “AHRQ had a study section that I thought … As we’re thinking about the design of a new model, we start doing our scanning and figuring out, “Well … I was thinking about the definition of “coordinating” as well, and I think there’s sometimes a third … As a consequence, a member of the HSR TEP encouraged
really thinking about, you know, what are the
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psnet.ahrq.gov/node/858167/psn-pdf
December 13, 2023 - A proposed approach to allegations of sexual boundary
violation in health care.
December 13, 2023
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.jcjq.2023.08.006.
https://psnet.a…
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psnet.ahrq.gov/node/34588/psn-pdf
January 04, 2017 - The Johns Hopkins Hospital: identifying and addressing
risks and safety issues.
January 4, 2017
Paine LA, Baker DR, Rosenstein BJ, et al. The Johns Hopkins Hospital: identifying and addressing risks
and safety issues. Jt Comm J Qual Saf. 2004;30(10):543-50.
https://psnet.ahrq.gov/issue/johns-hopkins-hospital-ident…
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integrationacademy.ahrq.gov/sites/default/files/2020-07/Update%20Geriatric%20Depression%20Scale-30.pdf
January 01, 2020 - Are you bothered by thoughts you can t get out of your head? YES / NO
7.
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effectivehealthcare.ahrq.gov/sites/default/files/web-based_willis_respondent.pdf
January 01, 2009 - skills
that
enable
long-‐term
shared
decision-‐making
Slide
10:
Final
Thoughts
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psnet.ahrq.gov/node/34757/psn-pdf
November 18, 2015 - Unity of Mistakes: A Phenomenological Interpretation of
Medical Work.
November 18, 2015
Paget MA. Philadelphia: Temple University Press; 2004.
https://psnet.ahrq.gov/issue/unity-mistakes-phenomenological-interpretation-medical-work
In this often described landmark text on the nature of medical error, Marianne Page…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mental-health-pregnant-protocol.pdf
August 24, 2023 - of harming the baby, including thoughts of extended suicidea,b
• Adherence to mental health treatmenta … Outcomes:
• Scores on psychological
assessments
• Cure/resolution of symptoms
• Suicidal thoughts … , attempted
suicide, or death by suicide
• Thoughts of harming the
baby, including thoughts of
extended … or death by suicide associated with
various nonpharmacological interventions
● Relative impact on thoughts … of harming the baby, including thoughts of extended suicide
associated with various nonpharmacological
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psnet.ahrq.gov/node/43819/psn-pdf
July 16, 2015 - Intercepting wrong-patient orders in a computerized
provider order entry system.
July 16, 2015
Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider
order entry system. Ann Emerg Med. 2015;65(6):679-686.e1. doi:10.1016/j.annemergmed.2014.11.017.
https://psnet.ahrq.g…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/binge-eating_clinician.pdf
May 01, 2016 - .
�� There is an increased risk of suicidal thinking and behavior in
children, adolescents, and young … These patients should be monitored for emergence and worsening of
suicidal thoughts and behaviors. … Cognitive behavioral therapy (CBT)
Psychotherapy that focuses on identifying relationships among
thoughts … , feelings, and behaviors and aims to change negative
thoughts about oneself and the world and, by doing
-
effectivehealthcare.ahrq.gov/sites/default/files/pdf/disruptive-behavior-disorder_consumer.pdf
August 01, 2016 - appetite
��Feeling tired or sleepy
��Stomach ache
��Atomoxetine may increase the risk of
suicidal thoughts … Feeling weak
��Stomach ache
��Upset stomach
��Rash
��Divalproex may increase the risk of suicidal
thoughts … ��Cold symptoms (stuffy nose
and sore throat)
��Aripiprazole may increase the risk of suicidal
thoughts
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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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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-215-depression-older-adults-executive-summary.pdf
March 01, 2019 - Hospitalization
• Mortality
• Seizures
• Serious adverse events
• Suicide/suicide attempt
• Suicidal thoughts … arrhythmia, ECG-QTc, falls, fractures, mortality, serious
ADEAE, seizures, sodium/hyponatremia, suicidal thoughts … placebo 1 RCT23 Any AE, blood pressure, ECG-arrhythmia, mortality, seizures,
serious AE, suicidal thoughts … RCT25
Any AE, blood pressure, cognitive function, ECG-QTc, fractures,
serious AE, sodium, suicidal thoughts … RCT25
Any AE, blood pressure, cognitive function, ECG-QTc, fractures,
serious AE, sodium, suicidal thoughts
-
psnet.ahrq.gov/node/34993/psn-pdf
June 22, 2009 - Five system barriers to achieving ultrasafe health care.
June 22, 2009
Amalberti R, Auroy Y, Berwick D, et al. Five system barriers to achieving ultrasafe health care. Ann Intern
Med. 2005;142(9):756-64.
https://psnet.ahrq.gov/issue/five-system-barriers-achieving-ultrasafe-health-care
This commentary builds on the…