-
psnet.ahrq.gov/node/40365/psn-pdf
February 12, 2014 - Strategies for learning from failure.
February 12, 2014
Edmondson A. Strategies of learning from failure. Harv Bus Rev. 2011;89(4):48-55, 137.
https://psnet.ahrq.gov/issue/strategies-learning-failure
Failures are inevitable in any industry, especially in one as complex as health care. The ability to learn from
fai…
-
psnet.ahrq.gov/primer/systems-approach
June 15, 2024 - There are many specific techniques that can be used to analyze errors, including retrospective methods
-
psnet.ahrq.gov/node/36544/psn-pdf
July 14, 2010 - Targeted chart review of pediatric patient safety events
identified by the Agency for Healthcare Research and
Quality's Patient Safety Indicators methodology.
July 14, 2010
Scanlon M, Miller MR, Harris JM, et al. Targeted Chart Review of Pediatric Patient Safety Events Identified
by the Agency for Healthcare Resea…
-
psnet.ahrq.gov/node/39101/psn-pdf
March 05, 2010 - Interventions to improve team effectiveness: a systematic
review.
March 5, 2010
Buljac-Samardzic M, van Doorn CMD-, van Wijngaarden JDH, et al. Interventions to improve team
effectiveness: a systematic review. Health Policy (New York). 2010;94(3):183-95.
doi:10.1016/j.healthpol.2009.09.015.
https://psnet.ahrq.gov…
-
psnet.ahrq.gov/issue/medical-errors-mandatory-reporting-voluntary-reporting-or-both
February 28, 2024 - Commentary
Medical errors: mandatory reporting, voluntary reporting, or both?
Citation Text:
Grepperud S. Medical Errors: Mandatory Reporting, Voluntary Reporting, or Both? European Journal of Law and Economics. 2005;20(1). doi:10.1007/s10657-005-1019-8.
Copy Citation
Format:
…
-
psnet.ahrq.gov/node/45190/psn-pdf
February 15, 2017 - Biases in detection of apparent "weekend effect" on
outcome with administrative coding data: population
based study of stroke.
February 15, 2017
Li L, Rothwell PM, Study OV. Biases in detection of apparent "weekend effect" on outcome with
administrative coding data: population based study of stroke. BMJ. 2016;353:…
-
psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - Table 1 ).( 4 ) Although other categorizations also exist, this commentary will use ISMP's model to analyze … Readers who also wish to analyze errors in this manner can use a worksheet available on ISMP's Web site
-
psnet.ahrq.gov/issue/discontinuity-and-disaster-gaps-and-negotiation-culpability-medication-delivery
June 24, 2020 - Commentary
Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery.
Citation Text:
Dekker SWA. Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. J Law Med Ethics. 2007;35(3):463-70.
Copy Citation
Format:…
-
psnet.ahrq.gov/node/40725/psn-pdf
October 16, 2012 - Association of ICU or hospital admission with
unintentional discontinuation of medications for chronic
diseases.
October 16, 2012
Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional
discontinuation of medications for chronic diseases. JAMA. 2011;306(8):840-7.
doi:10.10…
-
psnet.ahrq.gov/issue/strategies-learning-failure
September 25, 2024 - Commentary
Classic
Strategies for learning from failure.
Citation Text:
Edmondson A. Strategies of learning from failure. Harv Bus Rev. 2011;89(4):48-55, 137.
Copy Citation
Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnot…
-
psnet.ahrq.gov/node/33612/psn-pdf
May 01, 2005 - We embedded
in our practice a robust root cause analysis system to analyze critical incidents, report
-
psnet.ahrq.gov/issue/patient-safety-7
November 16, 2015 - Book/Report
Patient Safety.
Citation Text:
Patient Safety. Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.
Copy Citation
Save
Save to your library
Print
…
-
psnet.ahrq.gov/issue/nurses-role-patient-safety
June 09, 2011 - Commentary
Nurses' role in patient safety.
Citation Text:
Hughes RG, Clancy CM. Nurses' role in patient safety. J Nurs Care Qual. 2009;24(1):1-4. doi:10.1097/NCQ.0b013e31818f55c7.
Copy Citation
Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …
-
psnet.ahrq.gov/issue/systematic-review-incidence-and-characteristics-preventable-adverse-drug-events-ambulatory
July 15, 2010 - Review
Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care.
Citation Text:
Thomsen LA, Winterstein AG, S⊘ndergaard B, et al. Systematic Review of the Incidence and Characteristics of Preventable Adverse Drug Events in Ambulatory …
-
psnet.ahrq.gov/issue/nursing-student-errors-and-near-misses-three-years-data
October 20, 2021 - Study
Nursing student errors and near misses: three years of data.
Citation Text:
Silvestre JH, Spector ND. Nursing student errors and near misses: three years of data. J Nurs Educ. 2023;62(1):12-19. doi:10.3928/01484834-20221109-05.
Copy Citation
Format:
DOI Google Scholar…
-
psnet.ahrq.gov/issue/ambulance-stretcher-adverse-events
March 23, 2011 - Study
Ambulance stretcher adverse events.
Citation Text:
Wang HE, Weaver MD, Abo BN, et al. Ambulance stretcher adverse events. Qual Saf Health Care. 2009;18(3):213-216. doi:10.1136/qshc.2007.024562.
Copy Citation
Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML En…
-
psnet.ahrq.gov/issue/complication-rates-weekends-and-weekdays-us-hospitals
August 31, 2011 - Study
Complication rates on weekends and weekdays in US hospitals.
Citation Text:
Bendavid E, Kaganova Y, Needleman J, et al. Complication rates on weekends and weekdays in US hospitals. Am J Med. 2007;120(5):422-8.
Copy Citation
Format:
Google Scholar PubMed BibTeX EndNo…
-
psnet.ahrq.gov/issue/using-six-sigma-reduce-medication-errors-home-delivery-pharmacy-service
November 18, 2015 - Study
Using Six Sigma to reduce medication errors in a home-delivery pharmacy service.
Citation Text:
Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24.
Copy Citation
…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.72_slideshow.ppt
September 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case September 2004
Poor Prognosis?
Source and Credits
This presentation is based on the September 2004
AHRQ WebM&M Spotlight Case in Surgery
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Elizabeth B. Lamont, M…
-
psnet.ahrq.gov/node/38956/psn-pdf
March 18, 2015 - Safety in Doses.
March 18, 2015
London, UK: National Patient Safety Agency; 2009. ISBN: 9781906624088.
https://psnet.ahrq.gov/issue/safety-doses
This publication analyzes 72,482 medication incidents reported to the National Health Service and
highlights areas for improvement and prevention.
https://psnet.ahrq.gov…