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psnet.ahrq.gov/node/48097/psn-pdf
July 17, 2019 - Serious misdiagnosis-related harms in malpractice
claims: the "Big Three": vascular events, infections, and
cancers.
July 17, 2019
Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Serious misdiagnosis-related harms in malpractice
claims: The “Big Three” – vascular events, infections, and cancers. Diagnosis (Berl). …
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psnet.ahrq.gov/issue/good-bad-and-ugly-patient-experiences-crps
February 28, 2024 - Webinar
The Good, The Bad, and The Ugly: Patient Experiences with CRPs.
Citation Text:
The Good, The Bad, and The Ugly: Patient Experiences with CRPs. Collaborative for Accountability and Improvement. October 21, 2021.
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psnet.ahrq.gov/node/42789/psn-pdf
December 04, 2013 - Development of the just culture assessment tool:
measuring the perceptions of health-care professionals in
hospitals.
December 4, 2013
Petschonek S, Burlison JD, Cross C, et al. Development of the just culture assessment tool: measuring the
perceptions of health-care professionals in hospitals. J Patient Saf. 2013…
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psnet.ahrq.gov/node/43707/psn-pdf
November 26, 2014 - America's Hospitals: Improving Quality and Safety: The
Joint Commission's Annual Report 2014.
November 26, 2014
Oakbrook Terrace, IL: The Joint Commission; November 2014.
https://psnet.ahrq.gov/issue/americas-hospitals-improving-quality-and-safety-joint-commissions-annual-
report-2014
This Joint Commission annual…
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psnet.ahrq.gov/issue/adverse-events-and-perceived-abandonment-learning-patients-accounts-medical-mishaps
February 12, 2020 - Study
Adverse events and perceived abandonment: learning from patients' accounts of medical mishaps.
Citation Text:
Schlesinger M, Dhingra I, Fain BA, et al. Adverse events and perceived abandonment: learning from patients’ accounts of medical mishaps. BMJ Open Qual. 2024;13(3):e002848. …
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psnet.ahrq.gov/issue/independent-review-gross-negligence-manslaughter-and-culpable-homicide
July 08, 2019 - Book/Report
Independent Review of Gross Negligence Manslaughter and Culpable Homicide.
Citation Text:
Independent Review of Gross Negligence Manslaughter and Culpable Homicide. Manchester, UK: General Medical Council; June 2019.
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psnet.ahrq.gov/issue/middle-manager-responses-hospital-co-workers-unprofessional-behaviours-within-context
May 01, 2024 - Study
Middle manager responses to hospital co-workers' unprofessional behaviours within the context of a professional accountability culture change program: a qualitative analysis.
Citation Text:
Bagot KL, McInnes E, Mannion R, et al. Middle manager responses to hospital co-workers’ unpr…
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psnet.ahrq.gov/issue/improving-safety-and-security-veterans-act-2020
March 25, 2020 - Legislation/Case Law
Improving Safety and Security for Veterans Act of 2020.
Citation Text:
Improving Safety and Security for Veterans Act of 2020. HB 5616, 116th Congress: 2020.
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S…
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psnet.ahrq.gov/issue/drug-shortages-certain-factors-are-strongly-associated-persistent-public-health-challenge
May 04, 2016 - Book/Report
Drug Shortages: Certain Factors Are Strongly Associated With This Persistent Public Health Challenge.
Citation Text:
Drug Shortages: Certain Factors Are Strongly Associated With This Persistent Public Health Challenge. Washington, DC: United States Government Accountability O…
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psnet.ahrq.gov/issue/patient-safety-hhs-has-taken-steps-address-unsafe-injection-practices-more-action-needed
September 05, 2012 - Book/Report
Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed.
Citation Text:
Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed. Kohn LT. Washington, DC: United States Government Acc…
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psnet.ahrq.gov/issue/drug-shortages-public-health-threat-continues-despite-efforts-help-ensure-product
March 19, 2014 - Book/Report
Drug Shortages: Public Health Threat Continues, Despite Efforts to Help Ensure Product Availability.
Citation Text:
Drug Shortages: Public Health Threat Continues, Despite Efforts to Help Ensure Product Availability. Washington, DC: United States Government Accountability Off…
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psnet.ahrq.gov/issue/patient-safety-hospitals-face-challenges-implementing-evidence-based-practices
September 07, 2016 - Book/Report
Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices.
Citation Text:
Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices. Washington, DC: United States Government Accountability Office; February 2016. Publication GAO-16-3…
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psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - immediate waste of a controlled substance is not possible, processes should be developed to ensure fully accountable
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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - Tough Call: Addressing Errors From Previous Providers
March 1, 2014
Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
Case Objectives
Define what it means to be a professional.
Identi…
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psnet.ahrq.gov/node/48031/psn-pdf
May 22, 2019 - In harm's way.
May 22, 2019
Donaldson LJ, Lemer C, Titcombe J. In harm's way. BMJ. 2019;365:l2037. doi:10.1136/bmj.l2037.
https://psnet.ahrq.gov/issue/harms-way
This commentary recommends that health care structure the work environment to address conditions that
allow for failure. The authors discuss how increased…
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psnet.ahrq.gov/node/849337/psn-pdf
May 24, 2023 - Actions to renew focus on safety culture.
May 24, 2023
Salvon-Harman J. Healthcare Executive. 2023;39(3):48-49.
https://psnet.ahrq.gov/issue/actions-renew-focus-safety-culture
A strong safety work environment is core to reliable care delivery and staff wellbeing. This article discusses
how leadership should listen…
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psnet.ahrq.gov/node/74119/psn-pdf
November 24, 2021 - When we're all responsible for a patient's death, no one
is.
November 24, 2021
Prasad V, Medpage Today. November 16, 2021.
https://psnet.ahrq.gov/issue/when-were-all-responsible-patients-death-no-one
The issue of system versus individual accountability can challenge the orientation of safety improvement
effo…
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psnet.ahrq.gov/issue/improved-policies-and-oversight-needed-reviewing-and-reporting-providers-quality-and-safety
November 22, 2017 - Book/Report
Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.
Citation Text:
Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns. Washington, DC: United States Government …
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psnet.ahrq.gov/issue/indian-health-service-actions-needed-improve-use-data-adverse-events
September 07, 2016 - Book/Report
Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events.
Citation Text:
Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. Washington, DC: United States Government Accounting Office; July 10, 2023. Publication GAO-23-1…
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psnet.ahrq.gov/issue/we-may-remember-what-did-we-learn-dealing-errors-crimes-and-misdemeanours-around-adverse
December 29, 2014 - Commentary
We may remember but what did we learn? Dealing with errors, crimes and misdemeanours around adverse events in healthcare.
Citation Text:
Fischbacher-Smith D, Fischbacher-Smith M. WE MAY REMEMBER BUT WHAT DID WE LEARN? DEALING WITH ERRORS, CRIMES AND MISDEMEANOURS AROUND ADVE…