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  1. Speaking up to reduce noise in the OR. | PSNet

    psnet.ahrq.gov/issue/speaking-reduce-noise-or
    July 26, 2023 - Commentary Speaking up to reduce noise in the OR. Citation Text: Ford DA. Speaking Up to Reduce Noise in the OR. AORN J. 2015;102(1):85-9. doi:10.1016/j.aorn.2015.04.019. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…

  2. A 62-year-old woman with skin cancer who experienced wrong-site surgery. | PSNet

    psnet.ahrq.gov/issue/62-year-old-woman-skin-cancer-who-experienced-wrong-site-surgery
    December 01, 2021 - Commentary Classic A 62-year-old woman with skin cancer who experienced wrong-site surgery. Citation Text: Gallagher TH. A 62-year-old woman with skin cancer who experienced wrong-site surgery: review of medical error. JAMA. 2009;302(6):669-77. doi:10.1001/jam…

  3. Checklists, safety, my culture and me. | PSNet

    psnet.ahrq.gov/issue/checklists-safety-my-culture-and-me
    June 19, 2019 - Commentary Checklists, safety, my culture and me. Citation Text: Raghunathan K. Checklists, safety, my culture and me. BMJ Qual Saf. 2012;21(7):617-20. doi:10.1136/bmjqs-2011-000608. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endno…

  4. Disclosing harmful medical errors to patients: tackling three tough cases. | PSNet

    psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-tackling-three-tough-cases
    December 19, 2018 - Commentary Disclosing harmful medical errors to patients: tackling three tough cases. Citation Text: Gallagher TH, Bell SK, Smith KM, et al. Disclosing harmful medical errors to patients: tackling three tough cases. Chest. 2009;136(3):897-903. doi:10.1378/chest.09-0030. Copy Citation …

  5. Innovation in safety, and safety in innovation. | PSNet

    psnet.ahrq.gov/issue/innovation-safety-and-safety-innovation
    October 27, 2021 - Commentary Innovation in safety, and safety in innovation. Citation Text: Eisenberg D, Wren SM. Innovation in safety, and safety in innovation. JAMA Surg. 2014;149(1):7-9. doi:10.1001/jamasurg.2013.5112. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847043/psn-pdf
    April 05, 2023 - An evidence synthesis on perioperative handoffs: a call for balanced sociotechnical solutions. April 5, 2023 Abraham J, Duffy C, Kandasamy M, et al. An evidence synthesis on perioperative handoffs: a call for balanced sociotechnical solutions. Int J Med Inform. 2023;174:105038. doi:10.1016/j.ijmedinf.2023.105038. …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43847/psn-pdf
    January 28, 2015 - Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. January 28, 2015 Salazar MJB, Minkoff H, Bayya J, et al. Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. J Am Coll Surg. 2014;219(5):1001-7. doi:10.1016/j.jamcollsurg.201…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40563/psn-pdf
    September 09, 2011 - Shedding light on the dark side of doctor–patient interactions: verbal and nonverbal messages physicians communicate during error disclosures. September 9, 2011 Hannawa AF. Shedding light on the dark side of doctor-patient interactions: verbal and nonverbal messages physicians communicate during error disclosures.…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853970/psn-pdf
    September 27, 2023 - Clinical triggers and vital signs influencing crisis acknowledgment and calls for help by anesthesiologists: a simulation-based observational study. September 27, 2023 Matern LH, Gardner R, Rudolph JW, et al. Clinical triggers and vital signs influencing crisis acknowledgment and calls for help by anesthesiologist…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73426/psn-pdf
    June 23, 2021 - The perfect storm: exam of a medical error and factors contributing to its possible escalation. June 23, 2021 Walters GK. The perfect storm: exam of a medical error and factors contributing to its possible escalation. J Patient Saf. 2021;17(4):e264-e267. doi:10.1097/pts.0000000000000846. https://psnet.ahrq.gov/iss…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861292/psn-pdf
    January 24, 2024 - Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures. January 24, 2024 Washington DC: VA Office of the Inspector General; January 4, 2024; Report no. 22-02294-42. https://psnet.ahrq.gov/issue/deficiencies-community-care-n…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44663/psn-pdf
    September 27, 2016 - Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services. September 27, 2016 Mueller SK, Schnipper JL, Giannelli K, et al. Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services. J Hosp Med. 2016;11(9):620-…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47041/psn-pdf
    June 27, 2018 - Medicare takes aim at boomerang hospitalizations of nursing home patients. June 27, 2018 Rau J. Kaiser Health News. June 13, 2018. https://psnet.ahrq.gov/issue/medicare-takes-aim-boomerang-hospitalizations-nursing-home-patients Safety problems are common in nursing homes due to challenges such as poor safety cultu…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45815/psn-pdf
    January 25, 2017 - Handoffs: transitions of care for children in the emergency department. January 25, 2017 American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association Pediatric Committee. Pediatrics. 2016;138:…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73870/psn-pdf
    September 22, 2021 - Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery. September 22, 2021 Combs CA, Einerson BD, Toner LE. Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery. Am J Obstet Gynecol. 2021;225(5):b43-b49. doi:10.1016…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43744/psn-pdf
    December 03, 2014 - Mobile physician reporting of clinically significant events—a novel way to improve handoff communication and supervision of resident on call activities. December 3, 2014 Nabors C, Peterson SJ, Aronow WS, et al. Mobile physician reporting of clinically significant events-a novel way to improve handoff communication…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45031/psn-pdf
    February 18, 2017 - Information transfer in multidisciplinary operating room teams: a simulation-based observational study. February 18, 2017 Cumin D, Skilton C, Weller J. Information transfer in multidisciplinary operating room teams: a simulation- based observational study. BMJ Qual Saf. 2017;26(3):209-216. doi:10.1136/bmjqs-2015-00…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43065/psn-pdf
    April 09, 2014 - Multiprofessional team simulation training, based on an obstetric model, can improve teamwork in other areas of health care. April 9, 2014 van der Nelson HA, Siassakos D, Bennett J, et al. Multiprofessional team simulation training, based on an obstetric model, can improve teamwork in other areas of health care. A…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73092/psn-pdf
    March 31, 2021 - SAFER Care: improving caregiver comprehension of discharge instructions. March 31, 2021 Uong A, Philips K, Hametz P, et al. SAFER care: improving caregiver comprehension of discharge instructions. Pediatrics. 2021;147(4):e20200031. doi:10.1542/peds.2020-0031. https://psnet.ahrq.gov/issue/safer-care-improving-careg…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47975/psn-pdf
    May 29, 2019 - Surgical Innovation, New Techniques and Technologies: A Guide to Good Practice. May 29, 2019 London, UK: Royal College of Surgeons of England; 2019. https://psnet.ahrq.gov/issue/surgical-innovation-new-techniques-and-technologies-guide-good-practice Introducing innovations in practice involves taking calculated ri…
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