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psnet.ahrq.gov/node/50925/psn-pdf
February 19, 2020 - Report of the Independent Inquiry into the Issues Raised
by Paterson.
February 19, 2020
James G. House Commons Report 31. Department of Health and Social Care. London,
England: Crown Copyright; 2020. ISBN 9781528617284.
https://psnet.ahrq.gov/issue/report-independent-inquiry-issues-raised-paterson
Shari…
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psnet.ahrq.gov/node/867049/psn-pdf
October 30, 2024 - National Review of Maternity Services in England 2022 to
2024.
October 30, 2024
National Review Of Maternity Services In England 2022 To 2024. Newcastle Upon Tyne, UK: Care Quality
Commission; September 2024.
https://psnet.ahrq.gov/issue/national-review-maternity-services-england-2022-2024
Maternal safety is a gl…
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psnet.ahrq.gov/node/44736/psn-pdf
December 16, 2015 - Harms from discharge to primary care: mixed methods
analysis of incident reports.
December 16, 2015
Williams H, Edwards A, Hibbert P, et al. Harms from discharge to primary care: mixed methods analysis of
incident reports. Br J Gen Pract. 2015;65(641):e829-e837. doi:10.3399/bjgp15X687877.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/43776/psn-pdf
March 17, 2015 - Impact of anesthetic handover on mortality and morbidity
in cardiac surgery: a cohort study.
March 17, 2015
Hudson CCC, McDonald B, Hudson JKC, et al. Impact of anesthetic handover on mortality and morbidity in
cardiac surgery: a cohort study. J Cardiothorac Vasc Anesth. 2015;29(1):11-6.
doi:10.1053/j.jvca.2014.05…
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psnet.ahrq.gov/node/850929/psn-pdf
June 21, 2023 - Requirements for implementing a 'just culture' within
healthcare organisations: an integrative review.
June 21, 2023
Murray JS, Lee J, Larson S, et al. Requirements for implementing a ‘just culture’ within healthcare
organisations: an integrative review. BMJ Open Qual. 2023;12(2):e002237. doi:10.1136/bmjoq-2022-
0…
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psnet.ahrq.gov/node/47810/psn-pdf
March 13, 2019 - Debriefing in the OR: a quality improvement project.
March 13, 2019
Finch EP, Langston M, Erickson D, et al. Debriefing in the OR: A Quality Improvement Project. AORN J.
2019;109(3):336-344. doi:10.1002/aorn.12616.
https://psnet.ahrq.gov/issue/debriefing-or-quality-improvement-project
Debriefing has emerged as a s…
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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/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…