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psnet.ahrq.gov/issue/designing-patient-safety-developing-methods-integrate-patient-safety-concerns-design-process
December 14, 2010 - Book/Report
Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process.
Citation Text:
Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process. Joseph A, Quan X, Taylor E, Jelen M. Co…
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psnet.ahrq.gov/issue/risk-and-event-assessment
August 12, 2020 - Special or Theme Issue
Risk and Event Assessment.
Citation Text:
Risk and Event Assessment. Jt Comm J Qual Patient Saf. 2010;36:348-385.
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psnet.ahrq.gov/issue/high-reliability-organizations-healthcare-handbook-patient-safety-quality
July 31, 2019 - Book/Report
High Reliability Organizations: A Healthcare Handbook for Patient Safety & Quality.
Citation Text:
High Reliability Organizations: A Healthcare Handbook for Patient Safety & Quality. Oster C, Braaten J, eds. Indianapolis, IN: Sigma Theta Tau International; 2016. ISBN: 9781940…
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psnet.ahrq.gov/issue/organizing-reliability-guide-research-and-practice
April 01, 2020 - Book/Report
Organizing for Reliability: A Guide for Research and Practice.
Citation Text:
Organizing for Reliability: A Guide for Research and Practice. Ramanujam R, Roberts KH, eds. Stanford, CA: Stanford University Press; 2018. ISBN: 9780804793612.
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psnet.ahrq.gov/issue/implementing-closing-loop-safe-practices-diagnostic-results
March 10, 2021 - Book/Report
Implementing Closing the Loop. Safe Practices for Diagnostic Results
Citation Text:
Implementing Closing the Loop. Safe Practices for Diagnostic Results Partnership for HIT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2020.
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psnet.ahrq.gov/issue/care-delivery-within-community-mental-health-teams
April 26, 2023 - Book/Report
Care Delivery within Community Mental Health Teams.
Citation Text:
Care Delivery within Community Mental Health Teams. Farnborough, UK: Healthcare Safety Investigation Branch; March 2023.
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psnet.ahrq.gov/issue/safe-practices-drug-allergies-using-cds-and-health-it
March 10, 2021 - Book/Report
Safe Practices for Drug Allergies—Using CDS and Health IT.
Citation Text:
Safe Practices for Drug Allergies—Using CDS and Health IT. Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2019.
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psnet.ahrq.gov/issue/dont-abandon-second-victims-medical-errors
September 26, 2017 - Commentary
Don't abandon the "second victims" of medical errors.
Citation Text:
Smetzer JL. Don't abandon the "second victims" of medical errors. Nursing (Brux). 2012;42(2):54-8. doi:10.1097/01.NURSE.0000410310.38734.e0.
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psnet.ahrq.gov/issue/keeping-children-and-young-people-mental-health-needs-safe-design-paediatric-ward
February 21, 2024 - Book/Report
Keeping Children and Young People with Mental Health Needs Safe: the Design of the Paediatric Ward.
Citation Text:
Keeping Children and Young People with Mental Health Needs Safe: the Design of the Paediatric Ward. Dorset, UK: Health Services Safety Investigations Body; May 2…
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psnet.ahrq.gov/issue/made-whole-efficacy-legal-redress-black-women-who-have-suffered-injuries-medical-bias
February 23, 2022 - Commentary
Made whole: the efficacy of legal redress for black women who have suffered injuries from medical bias.
Citation Text:
Made whole: the efficacy of legal redress for black women who have suffered injuries from medical bias. Baker MB. Harv Civ Rights-Civil Lib Law Rev. 2022: 57(…
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psnet.ahrq.gov/issue/teamwork-and-communication-surgical-teams-implications-patient-safety
March 25, 2020 - Study
Teamwork and communication in surgical teams: implications for patient safety.
Citation Text:
Teamwork and communication in surgical teams: implications for patient safety. Mills P; Neily J; Dunn E.
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psnet.ahrq.gov/issue/understanding-and-addressing-pre-hospital-diagnostic-delays
May 15, 2024 - Special or Theme Issue
Understanding And Addressing Pre-Hospital Diagnostic Delays.
Citation Text:
Understanding And Addressing Pre-Hospital Diagnostic Delays. Health Affairs Forefront; May-September 2023.
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psnet.ahrq.gov/issue/unlabeled-containers-lead-patients-death
September 26, 2017 - Commentary
Unlabeled containers lead to patient's death.
Citation Text:
Cohen MR, Smetzer JL. Unlabeled containers lead to patient's death. Jt Comm J Qual Patient Saf. 2005;31(7):414-7.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-44
September 26, 2017 - Commentary
ISMP medication error report analysis.
Citation Text:
Cohen MR, Smetzer JL. Neuromuscular Blocker Mix-up in the Pharmacy; ISMP and Doctor's Digest Launch New iPhone Application; “UD” for “Ut Dictum”—an Ambiguous and Dangerous Abbreviation; Order by Metric Weight, Not Volume.…
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psnet.ahrq.gov/issue/10-derm-mistakes-you-dont-want-make
March 26, 2008 - Commentary
10 derm mistakes you don't want to make.
Citation Text:
Fox GN. 10 derm mistakes you don't want to make. J Fam Pract. 2008;57(3):162-9.
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psnet.ahrq.gov/node/43500/psn-pdf
November 17, 2014 - systematic-review-behavioural-marker-systems-healthcare-what-do-we-know-
about-their
Teamwork training programs encourage specific behaviors—formally
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psnet.ahrq.gov/node/47549/psn-pdf
March 04, 2019 - interventions-against-bullying-prelicensure-students-and-nursing-
professionals-integrative
Disrespectful behavior … education, nurse leadership development, and policy
interventions currently being applied to reduce these behaviors … interventions-against-bullying-prelicensure-students-and-nursing-professionals-integrative
https://psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior
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psnet.ahrq.gov/web-mm/its-sarah-not-stephen
January 01, 2015 - An 8-year-old child, born male who identified as and expressed externally (e.g., clothing, haircut, behavior … person expresses one's gender identity—it is illustrated through one's external characteristics and behaviors … Unfortunately, this leads to self-harming behaviors. … HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: implications … HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: implications
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psnet.ahrq.gov/node/49565/psn-pdf
July 01, 2008 - psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
behavior … since there was no evidence of intentional disregard of the risk of harm, she was exhibiting at-risk
behavior
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psnet.ahrq.gov/node/73303/psn-pdf
May 26, 2021 - Safety Culture in EMS
May 26, 2021
Cebollero C, Fitall E, Hall KK, et al. Safety Culture in EMS. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/safety-culture-ems
Defining a Just Culture
A Just Culture is one that supports transparent and honest error reporting with the goal of fostering an
environmen…