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5281. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861776/psn-pdf
      January 31, 2024 - The Sunday story: when hospitals don't say sorry. January 31, 2024 Rascoe A, Gorenstein D. National Public Radio. January 21, 2024. https://psnet.ahrq.gov/issue/sunday-story-when-hospitals-dont-say-sorry Openness about making mistakes is a challenge in health care due to fear of litigation and career damage. This …

5282. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44283/psn-pdf
      July 15, 2015 - An analysis of near misses identified by anesthesia providers in the intensive care unit. July 15, 2015 Lipshutz AKM, Caldwell JE, Robinowitz DL, et al. An analysis of near misses identified by anesthesia providers in the intensive care unit. BMC Anesthesiol. 2015;15:93. doi:10.1186/s12871-015-0075-z. https://psne…

5283. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44312/psn-pdf
      November 06, 2015 - Beyond the team: understanding interprofessional work in two North American ICUs. November 6, 2015 Alexanian JA, Kitto S, Rak KJ, et al. Beyond the Team: Understanding Interprofessional Work in Two North American ICUs. Crit Care Med. 2015;43(9):1880-6. doi:10.1097/CCM.0000000000001136. https://psnet.ahrq.gov/issue…

5284. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50457/psn-pdf
      October 09, 2019 - Combined SNA and LDA methods to understand adverse medical events October 9, 2019 Zhu L, Reychav I, McHaney R, et al. Combined SNA and LDA methods to understand adverse medical events. Int J Risk Saf Med. 2019;30(3):129-153. doi:10.3233/JRS-180052. https://psnet.ahrq.gov/issue/combined-sna-and-lda-methods-understa…

5285. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45229/psn-pdf
      July 13, 2016 - The WakeWings journey: creating a patient safety program. July 13, 2016 Mills E. The WakeWings Journey: Creating a Patient Safety Program. AORN J. 2016;103(6):636-9. doi:10.1016/j.aorn.2016.04.004. https://psnet.ahrq.gov/issue/wakewings-journey-creating-patient-safety-program Successful and sustainable implementa…

5286. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36130/psn-pdf
      September 29, 2010 - OZIS and the politics of safety: using ICT to create a regionally accessible patient medication record. September 29, 2010 Stoop AP, Bal R, Berg M. OZIS and the politics of safety: using ICT to create a regionally accessible patient medication record. Int J Med Inform. 2007;76 Suppl 1:S229-35. https://psnet.ahrq.g…

5287. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41156/psn-pdf
      March 02, 2012 - The implementation of a perioperative checklist increases patients' perioperative safety and staff satisfaction. March 2, 2012 Böhmer AB, Wappler F, Tinschmann T, et al. The implementation of a perioperative checklist increases patients' perioperative safety and staff satisfaction. Acta Anaesthesiol Scand. 2012;56(…

5288. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46762/psn-pdf
      February 14, 2018 - Patient Safety in Surgery. February 14, 2018 Stahel PF, ed. BioMed Central. ISSN: 1754-9493. https://psnet.ahrq.gov/issue/patient-safety-surgery-0 The specialty of surgery draws from both clinical and nontechnical skills for generalists and subspecialists to support safe care delivery. This journal covers a range …

5289. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73493/psn-pdf
      July 14, 2021 - Safety cases for digital health innovations: can they work? July 14, 2021 Sujan M, Habli I. Safety cases for digital health innovations: can they work? BMJ Qual Saf. 2021;30(12):1047-1050. doi:10.1136/bmjqs-2021-012983. https://psnet.ahrq.gov/issue/safety-cases-digital-health-innovations-can-they-work This commen…

5290. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60674/psn-pdf
      July 08, 2020 - Sway: Unravelling Unconscious Bias July 8, 2020 Agarwal P. London, UK: Bloomsbury Sigma; 2020. ISBN 9781472971357.  https://psnet.ahrq.gov/issue/sway-unravelling-unconscious-bias Implicit biases influence behavior and decision making. This publication discusses how a range of implicit biases affect legal…

5291. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37121/psn-pdf
      March 09, 2009 - An innovative mobile approach for patient safety services: the case of a Taiwan health care provider. March 9, 2009 Chao CC, Jen WY, Hung MC, et al. An innovative mobile approach for patient safety services: The case of a Taiwan health care provider. Technovation. 2007;27(6-7). doi:10.1016/j.technovation.2006.12.00…

5292. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45049/psn-pdf
      April 20, 2016 - Medical errors: disclosure styles, interpersonal forgiveness, and outcomes. April 20, 2016 Hannawa AF, Shigemoto Y, Little TD. Medical errors: Disclosure styles, interpersonal forgiveness, and outcomes. Social Sci Med. 2016;156:29-38. doi:10.1016/j.socscimed.2016.03.026. https://psnet.ahrq.gov/issue/medical-errors…

5293. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47463/psn-pdf
      October 17, 2018 - My human doctor. October 17, 2018 Peskin SM. New York Times. October 4, 2018. https://psnet.ahrq.gov/issue/my-human-doctor Error disclosures are difficult but important conversations that can have negative consequences for patients, clinicians, and organizations, even when they are done appropriately. This newspap…

5294. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41032/psn-pdf
      December 30, 2014 - Factors that influence the expected length of operation: results of a prospective study. December 30, 2014 Gillespie BM, Chaboyer W, Fairweather N. Factors that influence the expected length of operation: results of a prospective study. BMJ Qual Saf. 2012;21(1):3-12. doi:10.1136/bmjqs-2011-000169. https://psnet.ah…

5295. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37441/psn-pdf
      November 01, 2012 - Saving Mothers' Lives: Reviewing Maternal Deaths to Make Motherhood Safer—2003–2005. November 1, 2012 Lewis G, ed. London, England: Confidential Enquiry into Maternal and Child Health; 2007. ISBN: 9780953353682. https://psnet.ahrq.gov/issue/saving-mothers-lives-reviewing-maternal-deaths-make-motherhood-safer- 200…

5296. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73898/psn-pdf
      September 29, 2021 - A Thematic Analysis of HSIB's First 22 Investigations.  September 29, 2021 Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021. https://psnet.ahrq.gov/issue/thematic-analysis-hsibs-first-22-investigations In-depth failure investigations provide improvement insights for individuals and or…

5297. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74045/psn-pdf
      November 03, 2021 - ‘They treat me like I’m old and stupid’: seniors decry health providers’ age bias. November 3, 2021 Graham J. Kaiser Health News. October 20, 2021. https://psnet.ahrq.gov/issue/they-treat-me-im-old-and-stupid-seniors-decry-health-providers-age-bias Implicit biases permeate decision making and can impede safe and e…

5298. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47821/psn-pdf
      May 22, 2019 - Patient Safety. May 22, 2019 National Pharmacy Association; NPA. https://psnet.ahrq.gov/issue/patient-safety-15 This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It i…

5299. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47884/psn-pdf
      May 22, 2019 - Implementation and evaluation of a laboratory safety process improvement toolkit. May 22, 2019 Kwan BM, Fernald D, Ferrarone P, et al. Implementation and Evaluation of a Laboratory Safety Process Improvement Toolkit. J Am Board Fam Med. 2019;32(2):136-145. doi:10.3122/jabfm.2019.02.180109. https://psnet.ahrq.gov/i…

5300. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837710/psn-pdf
      July 20, 2022 - Independent Neurology Inquiry. July 20, 2022 Lockhart B, Mascie-Taylor H. Crown Copyright: London, England; June 2022.  ISBN 9781912313631. https://psnet.ahrq.gov/issue/independent-neurology-inquiry Misdiagnosis of neurological conditions, such as stroke, can lead to delays in treatment and patient morbidity…