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psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
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/perspective/conversation-john-g-reiling-phd
June 01, 2014 - For example, we thought putting medications at the bedside would lower medication errors, and it would … batch these rounding processes, go back to a nursing station, and download all of what they've been thinking … People talk about smart thinking, which is more aimed at how to create habits that will make you become … subconscious activities and the circumstances are the same, these habits become more accurate than thinking … RW : Thinking 10 to 20 years from now, what does the hospital room of the future look like?
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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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psnet.ahrq.gov/node/866995/psn-pdf
October 30, 2024 - historical details, serial physical exam
findings, laboratory and imaging results, and recommendations and thought … quickly, or — when we
actively decide to override this efficient but potentially error-prone form of thinking … Thinking, fast and slow. 1st pbk. ed. New York: Farrar, Straus and Giroux; 2013.
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu2.html
October 01, 2014 - As the team thought more about it, they were able to brainstorm more and more steps from the time a patient … Also, it is important to begin thinking early about sustaining the improvements you put into place (as
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu2.html
October 01, 2014 - As the team thought more about it, they were able to brainstorm more and more steps from the time a patient … Also, it is important to begin thinking early about sustaining the improvements you put into place (as
-
psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
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.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Emanuel_19.pdf
February 20, 2008 - suitable expertise, a governing council and an expert advisory group
(both made up of experts and major thought … Module 1 Breakout session Moving beyond blame to systems thinking
Module 2 Breakout session Applying … module units cover fundamental safety science and patient-centered
care material, such as systems thinking … (also underpinning the tipping-point principle) that broad social change occurs when one leader’s
thoughts
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/cJSpoZqW2M7czx_-GeTdtE
May 01, 2004 - care settings, contains 3 items assessing
suicide risk (all within the past month).10 Data on
suicidal thoughts … “Thoughts of death” had 100% sensitivity, 81%
specificity, and 5.9% positive predictive value for
detecting … mean
decrease
P < 0.00
Cognitive-Behavioral Counseling vs Usual Care
Cohort 1 mo 1 mo NR Suicidal
thoughts … The 3
study drugs showed no differences for the analogous
“suicidal thoughts” on the HAM-D, and the overall
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www.uspreventiveservicestaskforce.org/uspstf/document/final-evidence-summary48/suicide-risk-screening-2004
May 15, 2004 - settings, contains 3 items assessing suicide risk (all within the past month). 10 Data on suicidal thoughts … "Thoughts of death" had 100 percent sensitivity, 81 percent specificity, and 5.9 percent positive predictive … The 3 study drugs showed no differences for the analogous "suicidal thoughts" on the HAM-D, and the overall … Montgomery et al, 1978 66
Cohort
1 mo
1 mo
NR
Suicidal thoughts
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psnet.ahrq.gov/node/848107/psn-pdf
April 26, 2023 - Biases in the Diagnostic Process
Unconscious thinking in clinical decision making may contribute to … (type 1 thinking); and one
that is analytical and deliberative (type 2 thinking).1 Cognitive biases … Further, telling clinicians to slow down,
ostensibly to switch from type 1 to type 2 thinking, may not … The extent to which
cognitive shortcuts and unconscious thinking impact medical decisions has not been … human action with system-level factors that influence diagnostic safety,
misdiagnosis is still often thought
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
January 31, 2024 - Biases in the Diagnostic Process
Unconscious thinking in clinical decision making may contribute to … (type 1 thinking); and one that is analytical and deliberative (type 2 thinking). 1 Cognitive biases … Further, telling clinicians to slow down, ostensibly to switch from type 1 to type 2 thinking, may not … The extent to which cognitive shortcuts and unconscious thinking impact medical decisions has not been … human action with system-level factors that influence diagnostic safety, misdiagnosis is still often thought
-
psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - Gruen, MD, MBA, FACR is the Chief Medical Officer, Imaging at IBM Watson Health and is a thought leader … I was thinking with the differential diagnoses generators, some of them now can take the information
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effectivehealthcare.ahrq.gov/sites/default/files/s5.pdf
October 01, 2007 - conference in Rockville, Maryland, June 19–20, 2006
at which 70 experts gathered to share their current thinking … and Bayesian methods
for comparative effectiveness meta-analyses may have
some advantages.23
FINAL THOUGHTS
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - Although both approaches to thinking about problem representation have utility, we will focus primarily … which all team members – including patients and their families – can contribute and view one another's thoughts
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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
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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
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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…