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1701. Evaluating teamwork in a simulated obstetric environment. | PSNet
      psnet.ahrq.gov/issue/evaluating-teamwork-simulated-obstetric-environment
      November 04, 2009 - Study Evaluating teamwork in a simulated obstetric environment. Citation Text: Morgan PJ, Pittini R, Regehr G, et al. Evaluating teamwork in a simulated obstetric environment. Anesthesiology. 2007;106(5):907-915. Copy Citation Format: Google Scholar PubMed BibTeX EndNote …

1702. Improving patient safety and communication through care rounds in a pediatric oncology outpatient clinic. | PSNet
      psnet.ahrq.gov/issue/improving-patient-safety-and-communication-through-care-rounds-pediatric-oncology-outpatient
      January 14, 2011 - Commentary Improving patient safety and communication through care rounds in a pediatric oncology outpatient clinic. Citation Text: Blough CA, Walrath JM. Improving patient safety and communication through care rounds in a pediatric oncology outpatient clinic. J Nurs Care Qual. 2007;22…

1703. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47024/psn-pdf
      November 28, 2018 - FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management. November 28, 2018 MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 14, 2018. https://psnet.ahrq.gov/issue/fda-safety-communication-use-caution-implanted-pum…

1704. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851917/psn-pdf
      January 01, 2024 - Incivility in healthcare: the impact of poor communication. August 2, 2023 Guppy JH, Widlund H, Munro R, et al. Incivility in healthcare: the impact of poor communication. BMJ Lead. 2024;8(1):83-87. doi:10.1136/leader-2022-000717. https://psnet.ahrq.gov/issue/incivility-healthcare-impact-poor-communication Incivi…

1705. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44384/psn-pdf
      August 12, 2015 - Effective followership: a standardized algorithm to resolve clinical conflicts and improve teamwork. August 12, 2015 Sculli GL, Fore AM, Sine DM, et al. Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork. J Healthc Risk Manag. 2015;35(1):21-30. doi:10.1002/jhrm.21174…

1706. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45702/psn-pdf
      January 25, 2017 - Implantable infusion pumps in the magnetic resonance (MR) environment: FDA safety communication—important safety precautions. January 25, 2017 MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2017. https://psnet.ahrq.gov/issue/implantable-infusion-pumps-magnetic-resonance-mr-e…

1707. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44916/psn-pdf
      June 01, 2016 - Implementing situation-background-assessment- recommendation in an anaesthetic clinic and subsequent information retention among receivers: a prospective interventional study of postoperative handovers. June 1, 2016 Randmaa M, Swenne CL, Mårtensson G, et al. Implementing situation-background-assessment- recommend…

1708. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865540/psn-pdf
      April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration April 11, 2024 Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration The Case An 82-year-old woman presented to the Emergency Department (ED) for …

1709. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37294/psn-pdf
      May 21, 2013 - Improving Hand-Off Communication. May 21, 2013 Oakbrook Terrace lL: Joint Commission Resources; 2007. ISBN 9781599400907. https://psnet.ahrq.gov/issue/improving-hand-communication The process of transferring primary responsibility for patient care is commonly referred to as a handoff. Handoffs are inherently dange…

1710. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/856637/psn-pdf
      November 29, 2023 - Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow- Up Care at the Phoenix VA Health Care System in Arizona. November 29, 2023 Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07. https://psnet.ahrq.gov/issue/deficiencies-…

1711. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861778/psn-pdf
      January 31, 2024 - Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee. January 31, 2024 Washington, DC: The Veterans Affairs Inspector General; January 10, 2024. Report No. 23-00777-52. https://psnet.ahrq.gov/issue/care-deficiencies-and-l…

1712. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47450/psn-pdf
      March 27, 2019 - A qualitative evaluation of healthcare professionals' perceptions of adverse events focusing on communication and teamwork in maternity care. March 27, 2019 Rönnerhag M, Severinsson E, Haruna M, et al. A qualitative evaluation of healthcare professionals' perceptions of adverse events focusing on communication and…

1713. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46421/psn-pdf
      November 08, 2017 - A novel ICU hand-over tool: the glass door of the patient room. November 8, 2017 Wessman BT, Sona C, Schallom M. A Novel ICU Hand-Over Tool: The Glass Door of the Patient Room. J Intensive Care Med. 2017;32(8):514-519. doi:10.1177/0885066616653947. https://psnet.ahrq.gov/issue/novel-icu-hand-over-tool-glass-door-p…

1714. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44393/psn-pdf
      August 12, 2015 - FDA Drug Safety Communication: FDA warns about prescribing and dispensing errors resulting from brand name confusion with antidepressant Brintellix (vortioxetine) and antiplatelet Brilinta (ticagrelor). August 12, 2015 MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; July 30, 2015. https…

1715. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33803/psn-pdf
      January 01, 2015 - We need to work harder and smarter in communicating this information.

1716. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50612/psn-pdf
      October 30, 2019 - The Safety Challenges of Supervision and Night Coverage in Academic Residency October 30, 2019 Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency The Case…

1717. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867676/psn-pdf
      February 26, 2025 - Responding to Patient Safety Events February 26, 2025 Shaikh U. Responding to Patient Safety Events. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/responding-patient-safety-events Background Patient safety events that occur in health care facilities require prompt action to ensure that further harm is mit…

1718. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49423/psn-pdf
      November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…

1719. Failed Interpretation of Screening Tool: Delayed Treatment | PSNet
      psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
      August 20, 2018 - WebM&M Cases Critical Opportunity Lost March 1, 2015 Communicating

1720. The Wrong Shot: Error Disclosure | PSNet
      psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
      May 01, 2011 - Communicating empathically can be especially challenging in the setting of an error, when the patient's