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  1. Psn-Pdf (pdf file)

    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…

  2. Psn-Pdf (pdf file)

    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…

  3. Psn-Pdf (pdf file)

    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…

  4. Psn-Pdf (pdf file)

    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. …

  5. Psn-Pdf (pdf file)

    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…

  6. Psn-Pdf (pdf file)

    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-…

  7. Psn-Pdf (pdf file)

    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…

  8. Psn-Pdf (pdf file)

    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…

  9. Psn-Pdf (pdf file)

    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(…

  10. Psn-Pdf (pdf file)

    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…

  11. Psn-Pdf (pdf file)

    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…

  12. Psn-Pdf (pdf file)

    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…

  13. Psn-Pdf (pdf file)

    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…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41228/psn-pdf
    August 02, 2012 - Identifying the latent failures underpinning medication administration errors: an exploratory study. August 2, 2012 Lawton R, Carruthers S, Gardner P, et al. Identifying the latent failures underpinning medication administration errors: an exploratory study. Health Serv Res. 2012;47(4):1437-1459. doi:10.1111/j.1475…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47055/psn-pdf
    May 23, 2018 - Surgical checklists save lives—but once in a while, they don't. Why? May 23, 2018 Mukherjee S. New York Times Magazine. May 9, 2018. https://psnet.ahrq.gov/issue/surgical-checklists-save-lives-once-while-they-dont-why Checklists can coordinate action and communication to augment safety, but human and system factor…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40745/psn-pdf
    September 07, 2011 - A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers. September 7, 2011 Li P, Stelfox HT, Ghali WA. A Prospective Observational Study of Physician Handoff for Intensive-Care- Unit-to-Ward Patient Transfers. Am J Med. 2011;124(9). doi:10.1016/j.amjmed.2011.04.027. …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48039/psn-pdf
    August 07, 2019 - Utilization of a role-based head covering system to decrease misidentification in the operating room. August 7, 2019 Rosen DA, Criser AL, Petrone AB, et al. Utilization of a Role-Based Head Covering System to Decrease Misidentification in the Operating Room. J Patient Saf. 2019;15(4):e90-e93. doi:10.1097/PTS.00000…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50593/psn-pdf
    October 30, 2019 - Using video to assess and improve patient safety during simulated and actual neonatal resuscitation. October 30, 2019 Leone TA. Using video to assess and improve patient safety during simulated and actual neonatal resuscitation. Semin Perinatol. 2019;43(8):151179. doi:10.1053/j.semperi.2019.08.008. https://psnet.a…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47775/psn-pdf
    April 03, 2019 - Reducing diagnostic errors worldwide through diagnostic management teams. April 3, 2019 Verna R, Velazquez AB, Laposata M. Reducing Diagnostic Errors Worldwide Through Diagnostic Management Teams. Ann Lab Med. 2019;39(2):121-124. doi:10.3343/alm.2019.39.2.121. https://psnet.ahrq.gov/issue/reducing-diagnostic-error…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46562/psn-pdf
    April 16, 2018 - "To err is human" but disclosure must be taught: a simulation-based assessment study. April 16, 2018 Crimmins AC, Wong AH, Bonz JW, et al. "To Err Is Human" but Disclosure Must be Taught: A Simulation- Based Assessment Study. Simul Healthc. 2018;13(2):107-116. doi:10.1097/SIH.0000000000000273. https://psnet.ahrq.g…
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