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psnet.ahrq.gov/node/74067/psn-pdf
November 10, 2021 - Conflict resolution: applying aviation crew resource
management in healthcare.
November 10, 2021
Braverman A. Conflict resolution: applying aviation crew resource management in healthcare. Nurs
Manage. 2021;52(9):30-34. doi:10.1097/01.numa.0000771740.79361.1c.
https://psnet.ahrq.gov/issue/conflict-resolution-apply…
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psnet.ahrq.gov/node/40697/psn-pdf
October 31, 2011 - Real-time automated paging and decision support for
critical laboratory abnormalities.
October 31, 2011
Etchells E, Adhikari NKJ, Wu RC, et al. Real-time automated paging and decision support for critical
laboratory abnormalities. BMJ Qual Saf. 2011;20(11):924-30. doi:10.1136/bmjqs.2010.051110.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/60688/psn-pdf
July 15, 2020 - The COVID-19 pandemic: resilient organisational
response to a low-chance, high-impact event.
July 15, 2020
Lloyd-Smith MK. The COVID-19 pandemic: resilient organisational response to a low-chance, high-impact
event. BMJ Leader. 2020;4:109-112. doi:10.1136/leader-2020-000245.
https://psnet.ahrq.gov/issue/covid-19-p…
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psnet.ahrq.gov/node/866411/psn-pdf
July 31, 2024 - Simulation to Improve Patient Safety: Getting Started.
July 31, 2024
Deutsch ES, Bajaj K. Simulation To Improve Patient Safety: Getting Started. Rockville, MD: Agency for
Healthcare Research and Quality; July 2024. Publication No. 24-0055.
https://psnet.ahrq.gov/issue/simulation-improve-patient-safety-getting-start…
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psnet.ahrq.gov/node/60016/psn-pdf
March 04, 2020 - The influence of bullying on nursing practice errors: a
systematic review.
March 4, 2020
Johnson AH, Benham?Hutchins M. The Influence of Bullying on Nursing Practice Errors: A Systematic
Review. AORN J. 2020;111(2). doi:10.1002/aorn.12923.
https://psnet.ahrq.gov/issue/influence-bullying-nursing-practice-errors-sys…
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psnet.ahrq.gov/node/47341/psn-pdf
August 29, 2018 - AORN Position Statement on Criminalization of Human
Errors in the Perioperative Setting.
August 29, 2018
AORN Position Statement on Criminalization of Human Errors in the Perioperative Setting. AORN J.
2018;108(1):64-65. doi:10.1002/aorn.12292.
https://psnet.ahrq.gov/issue/aorn-position-statement-criminalization-h…
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psnet.ahrq.gov/node/46611/psn-pdf
January 01, 2021 - Sustaining teamwork behaviors through reinforcement of
TeamSTEPPS principles.
November 15, 2017
Lee S-H, Khanuja HS, Blanding RJ, et al. Sustaining Teamwork Behaviors Through Reinforcement of
TeamSTEPPS Principles. J Patient Saf. 2021;17(7):e582-e586. doi:10.1097/pts.0000000000000414.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/50888/psn-pdf
February 12, 2020 - Preventable closed claims in the AANA Foundation
closed malpractice claims database.
February 12, 2020
Kremer MJ, Hirsch M, Geisz-Everson M, et al. Preventable Closed Claims in the AANA Foundation Closed
Malpractice Claims Database. AANA J. 2019;87(6).
https://psnet.ahrq.gov/issue/preventable-closed-claims-aana-fo…
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psnet.ahrq.gov/node/44967/psn-pdf
March 16, 2016 - Wrong site surgery: a critical incident analysis of a near
miss.
March 16, 2016
Tichanow S. Wrong site surgery: A critical incident analysis of a near miss. J Perioper Pract. 2016;26(1-
2):11-5.
https://psnet.ahrq.gov/issue/wrong-site-surgery-critical-incident-analysis-near-miss
Despite efforts to prevent wrong-s…
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psnet.ahrq.gov/node/837422/psn-pdf
June 15, 2022 - Reported clinical incidents of children with intellectual
disability: a qualitative analysis.
June 15, 2022
Ong N, Mimmo L, Barnett D, et al. Reported clinical incidents of children with intellectual disability: a
qualitative analysis. Dev Med Child Neurol. 2022;64(11):1359-1365. doi:10.1111/dmcn.15262.
https://ps…
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psnet.ahrq.gov/node/72696/psn-pdf
February 03, 2021 - Exploring the association between organizational safety
climate, failure to rescue, and mortality in inpatient
surgical units.
February 3, 2021
Bacon CT, McCoy TP, Henshaw DS. Exploring the Association Between Organizational Safety Climate,
Failure to Rescue, and Mortality in Inpatient Surgical Units. J Nurs Adm. …
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psnet.ahrq.gov/node/44318/psn-pdf
December 04, 2016 - At the Precipice of Quality Health Care: The Role of the
Toxicologist in Enhancing Patient and Medication Safety.
December 4, 2016
J Med Toxicol. 2015;11(2):165-166, 252-273.
https://psnet.ahrq.gov/issue/precipice-quality-health-care-role-toxicologist-enhancing-patient-and-
medication-safety
This special issue hi…
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psnet.ahrq.gov/node/864855/psn-pdf
March 20, 2024 - Operating room organization and surgical performance: a
systematic review.
March 20, 2024
Pasquer A, Ducarroz S, Lifante JC, et al. Operating room organization and surgical performance: a
systematic review. Patient Saf Surg. 2024;18(1):5. doi:10.1186/s13037-023-00388-3.
https://psnet.ahrq.gov/issue/operating-room-…
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psnet.ahrq.gov/node/866255/psn-pdf
July 10, 2024 - Cyberattack led to harrowing lapses at Ascension
hospitals, clinicians say.
July 10, 2024
Pradhan R, Wells K. KFF Health News and Morning Edition, Michigan Public Radio: June 19, 2024.
https://psnet.ahrq.gov/issue/cyberattack-led-harrowing-lapses-ascension-hospitals-clinicians-say
Cybersecurity is increasingly see…
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psnet.ahrq.gov/node/43048/psn-pdf
April 02, 2014 - Building a Culture of Candour: a Review of the Threshold
for the Duty of Candour and of the Incentives for Care
Organisations to Be Candid.
April 2, 2014
Dalton D, Williams N. London, UK: The Royal College of Surgeons of England; March 2014.
https://psnet.ahrq.gov/issue/building-culture-candour-review-thresh…
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psnet.ahrq.gov/node/863759/psn-pdf
March 06, 2024 - Clinician responses to disruptive intraoperative
behaviour: patterns and norms identified from a
multinational survey.
March 6, 2024
Villafranca A, Fast I, Turick M, et al. Clinician responses to disruptive intraoperative behaviour: patterns
and norms identified from a multinational survey. Can J Anaesth. 2024;71(…
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psnet.ahrq.gov/node/47021/psn-pdf
May 02, 2018 - The impact of improving teamwork on patient outcomes
in surgery: a systematic review.
May 2, 2018
Sun R, Marshall DC, Sykes MC, et al. The impact of improving teamwork on patient outcomes in surgery: A
systematic review. Int J Surg. 2018;53:171-177. doi:10.1016/j.ijsu.2018.03.044.
https://psnet.ahrq.gov/issue/impa…
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psnet.ahrq.gov/node/34755/psn-pdf
September 06, 2011 - Safe Practices for Better Healthcare: 2006 Update.
September 6, 2011
Washington DC: National Quality Forum; 2007.
https://psnet.ahrq.gov/issue/safe-practices-better-healthcare-2006-update
The National Quality Forum used expert consensus and evidence review to identify 30 health care “safe
practices” that should be…
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psnet.ahrq.gov/node/73922/psn-pdf
October 06, 2021 - Leading causes of anesthesia-related liability claims in
ambulatory surgery centers.
October 6, 2021
Ranum D, Beverly A, Shapiro FE, et al. Leading causes of anesthesia-related liability claims in ambulatory
surgery centers. J Patient Saf. 2021;17(7):513-521. doi:10.1097/pts.0000000000000431.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/60234/psn-pdf
April 15, 2020 - Mistakes, Errors and Failures across Cultures.
April 15, 2020
Vanderheiden E, Mayer C, eds. Springer Nature. Cham, Switzerland: 2020. ISBN 9783030355739
https://psnet.ahrq.gov/issue/mistakes-errors-and-failures-across-cultures-navigating-potentials
Human error, mistakes and failure have cultural aspects that are im…