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  1. psnet.ahrq.gov/issue/impact-organizational-culture-preventability-assessment-selected-adverse-events-icu
    August 15, 2016 - Study Impact of organizational culture on preventability assessment of selected adverse events in the ICU: evaluation of morbidity and mortality conferences. Citation Text: Pelieu I, Djadi-Prat J, Consoli SM, et al. Impact of organizational culture on preventability assessment of selec…
  2. psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
    June 30, 2021 - In Conversation With... Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA June 30, 2021  Also Read the Essay Citation Text: In Conversation With.. Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA. PSNet [internet]. 2021.In Conversation…
  3. psnet.ahrq.gov/perspective/risk-management-and-patient-safety
    December 01, 2010 - Risk Management and Patient Safety Barry M. Manuel, MD; Jack L. McCarthy; William Berry, MD, MPH; Kathy Dwyer | December 1, 2010  Also Read a Conversation View more articles from the same authors. Citation Text: Manuel BM, McCarthy JL, Berry WR, et al. Risk Mana…
  4. psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph
    May 01, 2019 - In Conversation With… Jane Brice, MD, MPH May 1, 2019  Also Read an Essay Citation Text: In Conversation With… Jane Brice, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Co…
  5. psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
    March 01, 2017 - Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety Sara J. Singer, MBA, PhD | March 1, 2017  Also Read a Conversation View more articles from the same authors. Citation Text: Singer SJ. Our Maturing Understanding of Safety C…
  6. psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-disciplinary-actions-and-complaints-what-do-we-know
    July 01, 2017 - Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know? David Studdert, LLB, ScD | July 1, 2017  Also Read a Conversation View more articles from the same authors. Citation Text: Studdert DM. Doctors With Multiple Malprac…
  7. psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
    July 01, 2017 - In Conversation With… Michelle Mello, MPhil, JD, PhD July 1, 2017  Also Read an Essay Citation Text: In Conversation With… Michelle Mello, MPhil, JD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Hum…
  8. psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx Spotlight The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Source and Credits • This presentation is based on the November 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahr…
  9. psnet.ahrq.gov/perspective/covid-19-and-built-environment
    June 30, 2021 - COVID-19 and the Built Environment June 30, 2021  Also Read the Conversation View more articles from the same authors. Citation Text: Joseph A, Scanlon MM, Fitall E, et al. COVID-19 and the Built Environment. PSNet [internet]. Rockville (MD): Agency for Healthca…
  10. psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
    September 27, 2023 - SPOTLIGHT CASE Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations Citation Text: Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. Agency for Healthcare Research and Qu…
  11. psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
    May 01, 2019 - Safety in the Prehospital Emergency Medical Services Setting P. Daniel Patterson, PhD, NRP, and Donald M. Yealy, MD | May 1, 2019  Also Read a Conversation View more articles from the same authors. Citation Text: Patterson DP, Yealy DM. Safety in the Prehospital…
  12. psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
    August 01, 2018 - In Conversation With… Matthew Weinger, MD August 1, 2018  Also Read an Essay Citation Text: In Conversation With… Matthew Weinger, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …
  13. psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
    January 01, 2014 - In Conversation With… Hardeep Singh, MD, MPH December 1, 2013  Also Read an Essay Also Read an Essay Citation Text: In Conversation With… Hardeep Singh, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Heal…
  14. psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
    August 01, 2012 - SPOTLIGHT CASE The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Citation Text: Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
  15. psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
    November 16, 2022 - Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions Pascale Carayon, PhD; Nicole Werner, PhD; Anita Makkenchery, MPH; Sarah E. Mossburg, RN, PhD | November 16, 2022  Also Read the Conversation View more articles from the same aut…
  16. psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
    November 16, 2022 - In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD November 16, 2022  Also Read the Essay Citation Text: In Conversation With.. Pascale Carayon, PhD and Nicole Werner, PhD. PSNet [internet]. 2022.In Conversation With... Pascale Carayon, PhD and Ni…
  17. psnet.ahrq.gov/glossary
    January 01, 2003 - Glossary A B C D E F H I J L M N O P R S T U V W Active Error (or Active Failure) The terms active and latent as applied to errors were coined by Reason . Active errors occur at the point of contact between a human and some aspect of a larger system (e.g., a human–machine in…
  18. psnet.ahrq.gov/glossary-0
    January 01, 2003 - Glossary   Definitions abound in the medical error and patient safety literature, with subtle and not-so-subtle variations in the meanings of important terms. An effort was made to adopt the most straightforward terminology, with definitions that enjoy the widest use. A B C D E F H I J L M N O P R S T U…
  19. psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
    November 27, 2023 - In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety Joan Stanley, PhD, NP, FAAN, FAANP | November 27, 2023  Also Read the Essay View more articles from the same authors. Citation Text: Stanley J. In Conversat…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857059/psn-pdf
    November 29, 2023 - The Risks of a Malpositioned Gastrostomy Tube and Poor Communication November 29, 2023 Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication Disclosure of Relevant Financial …

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