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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - After subsequent discussion among the care team members, it was apparent the fellow and attending each thought
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/diabetes-foot-ulcer-amputation-prevalence_research.pdf
February 01, 2011 - These estimates are based on self-reports and
are thought to underestimate the true prevalence by one-third
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psnet.ahrq.gov/node/846975/psn-pdf
March 28, 2023 - Mothers may have thoughts such as, “I don't love
my baby,” “I don't look like a mom,” or “On social … I experienced a perinatal mental health condition myself, and I remember thinking that I must just not
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www.ahrq.gov/hai/tools/mvp/modules/technical/intro-daily-care-slides.html
February 01, 2017 - Only 17.7% of respondents thought it was easier to care for an awake and alert patient receiving mechanical
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psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
September 18, 2024 - However, we know very little about clinicians' thought processes in such cases. … The safety journal: lessons learned with an error reporting tool to stimulate systems thinking
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/antipsychotics-children_research-protocol.pdf
June 04, 2010 - Schizophrenia and related psychoses: positive and negative symptoms, disorganized
behavior, impaired thought … Children, adolescents, and young adults taking
antidepressants are at increased risk of
suicidal thinking … Children, adolescents, and young adults
taking antidepressants are at increased
risk of suicidal thinking … Children, adolescents, and young adults
taking antidepressants are at increased
risk of suicidal thinking … Adults
Increased mortality in elderly with
dementia-related psychosis
Increased risk of suicidal thinking
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psnet.ahrq.gov/node/863649/psn-pdf
February 28, 2024 - We started off the process thinking we could just revise the parts of
TeamSTEPPS needing updates and … The revised website and curriculum provide value to experienced trainers, people thinking about becoming
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psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
September 01, 2005 - They're also thinking about things like efficiency and risk management. … RW: From where you sit now, thinking back on how you were trained in medical school, what do you think … He did not shy away from tough questions when he thought about eliminating disparities in health care … paradigm for patient safety—moving away from individual blame to a richer understanding of systems thinking
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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
December 01, 2017 - How has life changed over the last 10 or 15 years in terms of systems thinking, and how do you and surgeons … Karl Bilimoria : It has evolved from the individual blame game to thinking about how to improve systems … [morbidity and mortality] conferences across the country have changed from blaming the presenter to thinking … When I read Birkmeyer's study, I thought: if I needed a surgeon for my dad I would want to know his or
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - medical diagnosis is not particularly valuable as an end unto itself, so diagnosis might be better thought … close, intermingled relationship, physicians often distinguish sharply between the diagnostic mode of thinking … but therapeutic uncertainty is ignored pending a confirmed diagnosis) and the therapeutic mode of thinking … "When the diagnosis is made, the thinking stops."
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
April 01, 2025 - The CUSP team applies systems thinking, seeking to understand the why behind the problem without blame … example: a sense of psychological safety facilitates multi-directional, open communication, and systems thinking … In other words, active failures are the adverse events we are used to thinking about and attempt to avoid … Slide 28
Important Messages to Share With Teams
SAY:
In thinking about the science of safety the
-
psnet.ahrq.gov/node/73553/psn-pdf
July 28, 2021 - They
spent a little time talking with the patient and telling them what they thought might be going … KH: You know, over the past year we've been paying more and more attention to telemedicine and
thinking … We began by thinking EMS
was a very important part of the emergency system.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/g2_pdi_specifictoolstosupportchange.pdf
January 01, 2011 - )X0007-5
Focused
Performance
Article Taking
Advantage of
Resistance to
Change (and the
TOC Thinking … Processes) to
Improve
Improvements
Explains how to use the TOC thinking
processes to leverage … It presents the thoughts,
successes, and failures of hospital leaders who
have used concepts of high … reduce
system failures and effectively respond when
failures do occur is the goal of high reliability
thinking
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/g2_combo_specifictoolstosupportchange.pdf
January 01, 2011 - )X0007-5
Focused
Performance
Article Taking
Advantage of
Resistance to
Change (and the
TOC Thinking … Processes) to
Improve
Improvements
Explains how to use the TOC thinking processes to
leverage … It presents the thoughts, successes, and
failures of hospital leaders who have used concepts
of high … reduce system failures and effectively
respond when failures do occur is the goal of high
reliability thinking
-
cdsic.ahrq.gov/sites/default/files/2023-05/InnovationCenterQ4ProgressReportFinalForDTPFINAL.pdf
January 01, 2023 - Stakeholders will be encouraged to
verbalize their thoughts and actions as they navigate the dashboard
-
digital.ahrq.gov/sites/default/files/InnovationCenterQ4ProgressReportFinalForDTPFINAL.pdf
January 01, 2024 - Stakeholders will be encouraged to
verbalize their thoughts and actions as they navigate the dashboard
-
www.ahrq.gov/sites/default/files/2025-03/taylor-report.pdf
January 01, 2025 - in a PDF and Excel-based format to help guide
the owner, design team, and diverse stakeholders in thinking … Most participants thought the tool
was a good start but would need more refinement in order to be useful … One participant thought training should be provided in the form of an online training
or half-day workshop … there are specific safety requirements or codes, designing for safety
is always something they are thinking … However, others pointed out that the toolkit helped the group in thinking through the design process.
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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX EndNote…
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psnet.ahrq.gov/web-mm/mitigating-risk-intrahospital-transport-pediatric-patients-risk-physiologic-instability
May 27, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability
Citation Text:
Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability. PSNet [internet]. Rockville (MD): Agency for Heal…
-
psnet.ahrq.gov/node/49528/psn-pdf
January 01, 2015 - The "Customer" Is Always Right
February 1, 2007
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/customer-always-right
Case Objectives
Understand the importance of identifying a patient's agenda.
Appreciate the factors that contribute to unmet patient expectations.
…