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  1. 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…

  2. 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…

  3. 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…

  4. 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. …

  5. 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…

  6. 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…

  7. 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…

  8. 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…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38544/psn-pdf
    September 02, 2009 - A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds. September 2, 2009 Liu SW, Thomas SH, Gordon JA, et al. A pilot study examining undesirable events among emergency department-boarded patients awaiting inpatient beds. Ann Emerg Med. 2009;54(3):381-5. do…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47583/psn-pdf
    December 05, 2018 - Interpersonal and organizational dynamics are key drivers of failure to rescue. December 5, 2018 Smith ME, Wells EE, Friese CR, et al. Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue. Health Aff (Millwood). 2018;37(11):1870-1876. doi:10.1377/hlthaff.2018.0704. https://psnet.ahrq.gov/…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852278/psn-pdf
    August 09, 2023 - Identifying failure modes in telemedicine: an instructional needs assessment. August 9, 2023 Monkman H, Kuziemsky C, Homco J, et al. Identifying failure modes in telemedicine: an instructional needs assessment. Stud Health Technol Inform. 2023;304:39-43. doi:10.3233/shti230365. https://psnet.ahrq.gov/issue/identif…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46663/psn-pdf
    November 29, 2017 - ISMP survey shows provider text messaging often runs afoul of patient safety. November 29, 2017 ISMP Medication Safety Alert! Acute Care Edition. November 16, 2017;22:1-5. https://psnet.ahrq.gov/issue/ismp-survey-shows-provider-text-messaging-often-runs-afoul-patient-safety Texting medication orders is convenient …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45506/psn-pdf
    November 30, 2016 - Is an indication-based prescribing system in our future? November 30, 2016 ISMP Medication Safety Alert! Acute Care Edition. November 17, 2016;21:1-5. https://psnet.ahrq.gov/issue/indication-based-prescribing-system-our-future Health information technology has enhanced prescribers' ability to document the purpose o…

  14. Measuring and Responding to Safety Culture Across Healthcare | Agency for Healthcare Research and Quality

    www.ahrq.gov/action-alliance/webinars/measuring-safety-culture.html
    May 01, 2025 - Measuring and Responding to Safety Culture Across Healthcare This webinar was the third of a three-part series on Safety Culture in Healthcare. On April 15, 2025, presenters discussed how to measure and improve safety culture using tools like AHRQ’s Surveys on Patient Safety Culture® (SOPS®) Program, the Safety…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46611/psn-pdf
    January 01, 2021 - Sustaining teamwork behaviors through reinforcement of TeamSTEPPS principles. November 15, 2017 Lee S-H, Khanuja HS, Blanding RJ, et al. Sustaining Teamwork Behaviors Through Reinforcement of TeamSTEPPS Principles. J Patient Saf. 2021;17(7):e582-e586. doi:10.1097/pts.0000000000000414. https://psnet.ahrq.gov/issue/…

  16. Implementing Self-Measured Blood Pressure in Primary Care Practices | Agency for Healthcare Research and Quality

    www.ahrq.gov/evidencenow/tools/implementing-smbp.html
    August 01, 2023 - Implementing Self-Measured Blood Pressure in Primary Care Practices Resource: Implementing SMBP HH4M-Lunch-Learn (4-27-22) (video, 51:18 minutes) In this webinar, American Medical Association (AMA) staff discuss how primary care practices can implement each of the 7 steps for implementing self-measured bl…

  17. Exhibit 6.15. Major Factors that Inhibited Lean Success | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-15.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 6.15. Major Factors that Inhibited Lean Success Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare Cas…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855437/psn-pdf
    November 15, 2023 - Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief. November 15, 2023 National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937. https://psnet.ahrq.gov/issue/advancing-diagnostic-excellence-maternal-h…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42539/psn-pdf
    September 27, 2016 - Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. September 27, 2016 Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36(1…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73452/psn-pdf
    June 30, 2021 - Administration of concentrated potassium chloride for injection during a code: still deadly! June 30, 2021 ISMP Medication Safety Alert! Acute care edition. June 3, 2021; 26(11): 1-5. https://psnet.ahrq.gov/issue/administration-concentrated-potassium-chloride-injection-during-code-still- deadly Concentrated …
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