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4681. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73548/psn-pdf
      July 27, 2021 - Diagnostic Errors in Primary Care. July 27, 2021 Betsy Lehman Center for Patient Safety. https://psnet.ahrq.gov/issue/diagnostic-errors-primary-care Case analysis provides important opportunities to highlight factors that culminate in diagnostic error. This website supports learning generated from the Primary-Care…

4682. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38021/psn-pdf
      August 27, 2008 - A review of the current evidence base for significant event analysis. August 27, 2008 Bowie P, Pope L, Lough M. A review of the current evidence base for significant event analysis. J Eval Clin Pract. 2008;14(4):520-36. doi:10.1111/j.1365-2753.2007.00908.x. https://psnet.ahrq.gov/issue/review-current-evidence-base…

4683. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50380/psn-pdf
      September 25, 2019 - Poetry and Medicine. Mistakes. September 25, 2019 Kittleson M. JAMA. 2019;322:984. https://psnet.ahrq.gov/issue/poetry-and-medicine-mistakes Medical mistakes are a source of anxiety for both patients and clinicians. This poem articulates a physician's perspective regarding the psychological impact of uncertainty a…

4684. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37028/psn-pdf
      April 11, 2009 - Multidisciplinary crisis simulations: the way forward for training surgical teams. April 11, 2009 Undre S, Koutantji M, Sevdalis N, et al. Multidisciplinary crisis simulations: the way forward for training surgical teams. World J Surg. 2007;31(9):1843-53. https://psnet.ahrq.gov/issue/multidisciplinary-crisis-simul…

4685. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42385/psn-pdf
      June 26, 2013 - Identifying and addressing preventable process errors in trauma care. June 26, 2013 Pucher PH, Aggarwal R, Twaij A, et al. Identifying and addressing preventable process errors in trauma care. World J Surg. 2013;37(4):752-8. doi:10.1007/s00268-013-1917-9. https://psnet.ahrq.gov/issue/identifying-and-addressing-pre…

4686. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36765/psn-pdf
      August 10, 2011 - Factors influencing perioperative nurses' error reporting preferences. August 10, 2011 Espin S, Regehr G, Levinson W, et al. Factors influencing perioperative nurses' error reporting preferences. AORN J. 2007;85(3):527-43. https://psnet.ahrq.gov/issue/factors-influencing-perioperative-nurses-error-reporting-prefer…

4687. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36571/psn-pdf
      January 05, 2017 - The Objective Structured Clinical Examination as an educational tool in patient safety. January 5, 2017 Varkey P, Natt N. The Objective Structured Clinical Examination as an educational tool in patient safety. Jt Comm J Qual Patient Saf. 2007;33(1):48-53. https://psnet.ahrq.gov/issue/objective-structured-clinical-…

4688. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41656/psn-pdf
      September 05, 2012 - ACOG SCOPE: Safety Certification in Outpatient Practice Excellence for Women's Health. September 5, 2012 Sclafani J, Levy BS, Lawrence H, et al. Building a Better Safety Net. doi:10.1097/aog.0b013e318260957c. https://psnet.ahrq.gov/issue/acog-scope-safety-certification-outpatient-practice-excellence-womens-health …

4689. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42737/psn-pdf
      November 20, 2019 - HANYS' Report on Report Cards. November 20, 2019 Rensselaer, NY: Healthcare Association of New York State; November 2019. https://psnet.ahrq.gov/issue/hanys-report-report-cards This publication assessed 12 widely disseminated hospital report cards by criteria including transparency of methodology, evidence-based m…

4690. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50900/psn-pdf
      February 12, 2020 - How to "DEAL" with disruptive physician behavior. February 12, 2020 Junga Z, Tritsch A, Singla M. How to “DEAL” With disruptive physician behavior. Gastroenterology. 2019;157(6):1469-1472. doi:10.1053/j.gastro.2019.10.021. https://psnet.ahrq.gov/issue/how-deal-disruptive-physician-behavior In this commentary, the …

4691. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47675/psn-pdf
      November 28, 2023 - SOPS Surveys. November 28, 2023 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/sops-surveys Surveys are established mechanisms for organizational assessment of safety culture. This collection of webinars provides an overview of the AHRQ Surveys on Patient Safety Culture™ (SOPS®) and a ran…

4692. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43360/psn-pdf
      September 29, 2017 - Antimicrobial Stewardship Toolkit. September 29, 2017 Chicago, IL: American Hospital Association Physician Leadership Forum; July 2014. https://psnet.ahrq.gov/issue/antimicrobial-stewardship-toolkit Antimicrobial stewardship has been promoted as an element of patient safety. This toolkit provides resources for hos…

4693. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867770/psn-pdf
      March 01, 2022 - Toolkit for Decolonization of Non-ICU Patients with Devices. March 1, 2022 Agency for Healthcare Research and Quality. Toolkit for Decolonization of Non-ICU Patients with Devices. https://psnet.ahrq.gov/issue/toolkit-decolonization-non-icu-patients-devices Healthcare associated infection is a persistent contributo…

4694. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36911/psn-pdf
      September 01, 2011 - Managing clinical failure: a complex adaptive system perspective. September 1, 2011 Matthews JI, Thomas PT. Managing clinical failure: a complex adaptive system perspective. Int J Health Care Qual Assur. 2007;20(3):184-194. doi:10.1108/09526860710743336. https://psnet.ahrq.gov/issue/managing-clinical-failure-compl…

4695. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36151/psn-pdf
      September 29, 2010 - Communication and teamwork in patient care: how much can we learn from aviation? September 29, 2010 Lyndon A. Communication and teamwork in patient care: how much can we learn from aviation? J Obstet Gynecol Neonatal Nurs. 2006;35(4):538-46. https://psnet.ahrq.gov/issue/communication-and-teamwork-patient-care-how-…

4696. In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles | PSNet
      psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
      August 28, 2024 - Traditional root cause analysis limits the learning that can be gained from assessing adverse events

4697. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49763/psn-pdf
      June 01, 2016 - July Syndrome June 1, 2016 Young JQ. July Syndrome. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/july-syndrome The Case A 64-year-old man was seen in the thoracic surgery clinic in June after being diagnosed with a right lower lobe lung cancer. The attending surgeon saw the patient along with his fellow,…

4698. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49809/psn-pdf
      October 01, 2017 - Hyperbilirubinemia Refractory to Phototherapy October 1, 2017 Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy The Case A 1-day-old full-term infant was noted to have elevated total serum bilirubin (…

4699. Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling | PSNet
      psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
      June 28, 2023 - Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL January 31, 2024 Innovation Contact …

4700. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60332/psn-pdf
      May 13, 2020 - Circle Up Training. May 13, 2020 Center for Medical Simulation. https://psnet.ahrq.gov/issue/circle-training Communication strategies are important for engaging staff in behaviors that support effective teamwork. This website highlights a process that involves briefings, supportive conversations, and debriefings a…