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psnet.ahrq.gov/node/44135/psn-pdf
November 06, 2015 - Freedom to Speak Up: A Review of Whistleblowing in the
NHS.
November 6, 2015
Francis R. London, UK: Department of Health; February 2015.
https://psnet.ahrq.gov/issue/freedom-speak-review-whistleblowing-nhs
Staff willingness to raise awareness of problems that could affect patient care is an important indicator of
…
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psnet.ahrq.gov/issue/safety-skills-training-surgeons-half-day-intervention-improves-knowledge-attitudes-and
September 26, 2012 - Study
Safety skills training for surgeons: a half-day intervention improves knowledge, attitudes and awareness of patient safety.
Citation Text:
Arora S, Sevdalis N, Ahmed M, et al. Safety skills training for surgeons: A half-day intervention improves knowledge, attitudes and awareness…
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psnet.ahrq.gov/node/48181/psn-pdf
August 07, 2019 - Managing the risks of direct oral anticoagulants.
August 7, 2019
Sentinel Event Alert. July 30, 2019;(61):1-5.
https://psnet.ahrq.gov/issue/managing-risks-direct-oral-anticoagulants
Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral
anticoagulants (DOACs) require less…
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psnet.ahrq.gov/node/44174/psn-pdf
January 06, 2016 - Team training for safer birth.
January 6, 2016
Cornthwaite K, Alvarez M, Siassakos D. Team training for safer birth. Best Pract Res Clin Obstet Gynaecol.
2015;29(8):1044-1057. doi:10.1016/j.bpobgyn.2015.03.020.
https://psnet.ahrq.gov/issue/team-training-safer-birth
Obstetric care is considered a high-risk environm…
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psnet.ahrq.gov/node/38904/psn-pdf
September 02, 2009 - Litigation related to inadequate anaesthesia: an analysis
of claims against the NHS in England 1995-2007.
September 2, 2009
Mihai R, Scott SD, Cook TM. Litigation related to inadequate anaesthesia: an analysis of claims against the
NHS in England 1995-2007. Anaesthesia. 2009;64(8):829-35. doi:10.1111/j.1365-2044.20…
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psnet.ahrq.gov/issue/high-cost-low-frequency-events-anatomy-and-economics-surgical-mishaps
October 19, 2022 - Study
Classic
The high cost of low-frequency events: the anatomy and economics of surgical mishaps.
Citation Text:
Couch NP, Tilney NL, Rayner AA, et al. The high cost of low-frequency events: the anatomy and economics of surgical mishaps. N Engl J Med. 1981;3…
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psnet.ahrq.gov/issue/can-we-make-airway-management-even-safer-lessons-national-audit
March 01, 2023 - Review
Can we make airway management (even) safer?—lessons from national audit.
Citation Text:
Woodall N, Frerk C, Cook TM. Can we make airway management (even) safer?--lessons from national audit. Anaesthesia. 2011;66 Suppl 2:27-33. doi:10.1111/j.1365-2044.2011.06931.x.
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psnet.ahrq.gov/issue/methods-increase-reliability-quality-improvement-projects
October 20, 2021 - Commentary
Methods to increase reliability in quality improvement projects.
Citation Text:
Lenk MA, LaMantia S, Oehler J, et al. Methods to increase reliability in quality improvement projects. Hosp Pediatr. 2024;14(8):e372-e377. doi:10.1542/hpeds.2023-007340.
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Format:…
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psnet.ahrq.gov/issue/human-factors-recognising-and-minimising-errors-our-day-day-practice
October 09, 2016 - Review
Human factors—recognising and minimising errors in our day to day practice.
Citation Text:
Green B, Tsiroyannis C, Brennan PA. Human factors--recognising and minimising errors in our day to day practice. Oral Dis. 2016;22(1):19-22. doi:10.1111/odi.12384.
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Format…
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psnet.ahrq.gov/node/840153/psn-pdf
November 16, 2022 - Team debriefing in the COVID-19 pandemic: a qualitative
study of a hospital-wide clinical event debriefing program
and a novel qualitative model to analyze debriefing
content.
November 16, 2022
Welch-Horan TB, Mullan PC, Momin Z, et al. Team debriefing in the COVID-19 pandemic: a qualitative
study of a hospital-w…
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psnet.ahrq.gov/node/43355/psn-pdf
July 23, 2014 - Nearing zero...reducing grade C medication errors.
July 23, 2014
Cockerham J, Figueroa-Altmann A, Foxen C, et al. Nearing zero..reducing grade C medication errors. Nurs
Manage. 2014;45(7):26-31. doi:10.1097/01.NUMA.0000451033.38845.d3.
https://psnet.ahrq.gov/issue/nearing-zeroreducing-grade-c-medication-errors
Thi…
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psnet.ahrq.gov/node/47555/psn-pdf
November 14, 2018 - How one hospital improved patient safety in 10 minutes a
day.
November 14, 2018
van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018.
https://psnet.ahrq.gov/issue/how-one-hospital-improved-patient-safety-10-minutes-day
Aviation continues to provide inspiration for patient safety innovation. This commentar…
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psnet.ahrq.gov/node/41358/psn-pdf
July 06, 2012 - Safety skills training for surgeons: a half-day intervention
improves knowledge, attitudes and awareness of patient
safety.
July 6, 2012
Arora S, Sevdalis N, Ahmed M, et al. Safety skills training for surgeons: A half-day intervention improves
knowledge, attitudes and awareness of patient safety. Surgery. 2012;152…
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psnet.ahrq.gov/node/44443/psn-pdf
September 09, 2015 - Using multidisciplinary rounds to improve patient safety
through venous thromboembolism prevention awareness.
September 9, 2015
Karasin B, Maund C. Using Multidisciplinary Rounds to Improve Patient Safety Through Venous
Thromboembolism Prevention Awareness. Jt Comm J Qual Patient Saf. 2015;41(9):428-431.
https://p…
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psnet.ahrq.gov/node/44764/psn-pdf
February 10, 2016 - Human factors—recognising and minimising errors in our
day to day practice.
February 10, 2016
Green B, Tsiroyannis C, Brennan PA. Human factors--recognising and minimising errors in our day to day
practice. Oral Dis. 2016;22(1):19-22. doi:10.1111/odi.12384.
https://psnet.ahrq.gov/issue/human-factors-recognising-an…
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psnet.ahrq.gov/issue/prospective-study-evaluate-awareness-about-medication-errors-amongst-health-care-personnel
May 17, 2018 - Study
A prospective study to evaluate awareness about medication errors amongst health-care personnel representing North, East, West Regions of India.
Citation Text:
Sewal RK, Singh PK, Prakash A, et al. A prospective study to evaluate awareness about medication errors amongst health-c…
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psnet.ahrq.gov/node/46425/psn-pdf
September 13, 2017 - Optimizing Crisis Resource Management to Improve
Patient Safety and Team Performance--A Handbook for
Acute Care Health Professionals.
September 13, 2017
Brindley P, Cardinal P, eds. Ottawa, ON, Canada: Royal College of Physicians and Surgeons of Canada;
2017. ISBN: 9781926588414.
https://psnet.ahrq.gov/issue/opti…
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psnet.ahrq.gov/node/45073/psn-pdf
May 11, 2016 - Promoting patient safety: results of a TeamSTEPPS
initiative.
May 11, 2016
Gaston T, Short N, Ralyea C, et al. Promoting patient safety: results of a TeamSTEPPS initiative. J Nurs
Adm. 2016;46(4):201-207. doi:10.1097/nna.0000000000000333.
https://psnet.ahrq.gov/issue/promoting-patient-safety-results-teamstepps-ini…
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psnet.ahrq.gov/node/46978/psn-pdf
April 04, 2018 - Using the patient safety huddle as a tool for high
reliability.
April 4, 2018
Brass SD, Olney G, Glimp R, et al. Using the Patient Safety Huddle as a Tool for High Reliability. Jt Comm
J Qual Patient Saf. 2018;44(4):219-226. doi:10.1016/j.jcjq.2017.10.004.
https://psnet.ahrq.gov/issue/using-patient-safety-huddle-t…
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psnet.ahrq.gov/issue/impact-relocation-new-critical-care-building-pediatric-safety-events
May 27, 2020 - Study
Impact of a relocation to a new critical care building on pediatric safety events.
Citation Text:
Furthmiller A, Sahay R, Zhang B, et al. Impact of a relocation to a new critical care building on pediatric safety events. J Hosp Med. 2024;19(5):589-595. doi:10.1002/jhm.13324.
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