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psnet.ahrq.gov/issue/patient-safety-and-problem-many-hands
June 16, 2021 - Commentary
Patient safety and the problem of many hands.
Citation Text:
Dixon-Woods M, Pronovost P. Patient safety and the problem of many hands. BMJ Qual Saf. 2016;25(7):485-488. doi:10.1136/bmjqs-2016-005232.
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psnet.ahrq.gov/node/35594/psn-pdf
January 04, 2006 - VA Patient Safety Program: A Cultural Perspective at Four
Medical Facilities.
January 4, 2006
General Accounting Office. Washington, DC: Government Printing Office; 2004. Report no. GAO-05-83.
https://psnet.ahrq.gov/issue/va-patient-safety-program-cultural-perspective-four-medical-facilities
The Government Account…
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psnet.ahrq.gov/node/73088/psn-pdf
March 31, 2021 - Nurses’ perspectives on the impact of management
approaches on the blame culture in health-care
organizations.
March 31, 2021
Okpala P. Nurses’ perspectives on the impact of management approaches on the blame culture in health-
care organizations. Int J Healthc Manage. 2020;13(sup1):199-205. doi:10.1080/20479700.2…
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psnet.ahrq.gov/node/838132/psn-pdf
September 21, 2022 - Pathology trainees rarely report safety incidents: a review
of 13,722 safety reports and a call to action.
September 21, 2022
Harris CK, Chen Y, Yarsky B, et al. Pathology trainees rarely report safety incidents: a review of 13,722
safety reports and a call to action. Acad Pathol. 2022;9(1):100049. doi:10.1016/j.ac…
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psnet.ahrq.gov/node/60518/psn-pdf
May 27, 2020 - Infection Control Deficiencies Were Widespread and
Persistent in Nursing Homes Prior to COVID-19 Pandemic.
May 27, 2020
Washington, DC: United States Government Accountability Office; May 20, 2020. Publication GAO-20-
576R.
https://psnet.ahrq.gov/issue/infection-control-deficiencies-were-widespre…
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psnet.ahrq.gov/issue/artificial-intelligence-health-care-benefits-and-challenges-machine-learning-technologies
October 12, 2022 - Book/Report
Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics.
Citation Text:
Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics. Washington DC: Un…
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psnet.ahrq.gov/issue/covid-19-nursing-homes-cms-needs-continue-strengthen-oversight-infection-prevention-and
October 26, 2022 - Book/Report
COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control.
Citation Text:
COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control. Washington, DC: United States Government …
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psnet.ahrq.gov/node/39017/psn-pdf
October 14, 2009 - Just culture: who gets to draw the line?
October 14, 2009
Dekker SWA. Just culture: who gets to draw the line? Cognition, Technology & Work. 2008;11(3).
doi:10.1007/s10111-008-0110-7.
https://psnet.ahrq.gov/issue/just-culture-who-gets-draw-line
This commentary explores the just culture concept and how the assignme…
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psnet.ahrq.gov/issue/behind-human-error-second-edition
April 13, 2018 - Book/Report
Classic
Behind Human Error, Second Edition.
Citation Text:
Behind Human Error, Second Edition. Woods DD, Dekker S, Cook R, Johannesen L. Boca Raton, FL: CRC Press; 2017. ISBN: 9781317175537.
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psnet.ahrq.gov/issue/transferring-responsibility-and-accountability-maternity-care-clinicians-defining-their
August 19, 2009 - Study
Transferring responsibility and accountability in maternity care: clinicians defining their boundaries of practice in relation to clinical handover.
Citation Text:
Chin GSM, Warren N, Kornman L, et al. Transferring responsibility and accountability in maternity care: clinicians d…
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psnet.ahrq.gov/issue/national-statutory-reporting-not-even-ticking-boxes-quality-learning-deaths-reporting-quality
February 22, 2023 - Study
National statutory reporting: not even ticking the boxes? The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020.
Citation Text:
Brummell Z, Braun D, Hussein Z, et al. National statutory reporting: not even ticking the boxes? The qua…
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psnet.ahrq.gov/node/842763/psn-pdf
January 18, 2023 - Implementation of peer messengers to deliver feedback:
an observational study to promote professionalism in
nursing.
January 18, 2023
Baldwin CA, Hanrahan K, Edmonds SW, et al. Implementation of peer messengers to deliver feedback: an
observational study to promote professionalism in nursing. Jt Comm J Qual Patien…
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psnet.ahrq.gov/node/50443/psn-pdf
October 09, 2019 - Medicare's Hospital-Acquired Condition Reduction
Program and community diversity in the United States:
the need to account for racial and ethnic segregation.
October 9, 2019
Hamadi H, Tafili A, Apatu E, et al. Medicare' Hospital-Acquired Condition Reduction Program and
Community Diversity in the United States: The…
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psnet.ahrq.gov/issue/safer-place-patients-learning-improve-patient-safety-0
June 22, 2016 - Book/Report
A Safer Place for Patients: Learning to Improve Patient Safety.
Citation Text:
A Safer Place for Patients: Learning to Improve Patient Safety. House of Commons Committee on Public Accounts. London: The Stationery Office Limited; June 2006.
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…
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psnet.ahrq.gov/node/38219/psn-pdf
May 24, 2015 - The emotional impact of medical error involvement on
physicians: a call for leadership and organisational
accountability.
May 24, 2015
Schwappach DL, Boluarte TA. The emotional impact of medical error involvement on physicians: a call for
leadership and organisational accountability. Swiss Med Wkly. 2009;139(1-2):…
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psnet.ahrq.gov/issue/va-health-care-improvements-needed-processes-used-address-providers-actions-contribute
October 12, 2022 - Book/Report
VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events.
Citation Text:
VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events. Draper D. Washington,…
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psnet.ahrq.gov/issue/ageing-surgeon-qualitative-study-expert-opinions-assuring-performance-and-supporting-safe
May 05, 2021 - Study
The ageing surgeon: a qualitative study of expert opinions on assuring performance and supporting safe career transitions among older surgeons.
Citation Text:
Sherwood R, Bismark M. The ageing surgeon: a qualitative study of expert opinions on assuring performance and supporting sa…
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - Everyone in the practice, including residents, attendings, nurses, and staff, are accountable for performance
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - surgical site, rather than relying on external agencies or systems, so all providers of care are held accountable
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psnet.ahrq.gov/node/45386/psn-pdf
November 23, 2016 - Balancing doctor egos and errors.
November 23, 2016
Sweeney JF. Medical Economics. November 10, 2016.
https://psnet.ahrq.gov/issue/balancing-doctor-egos-and-errors
Disclosure and candor with patients after a medical error has gained support from organizations, clinicians,
and patients. This magazine article discus…