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7901. Communication failures: an insidious contributor to medical mishaps. | PSNet
      psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps
      February 24, 2011 - Study Classic Communication failures: an insidious contributor to medical mishaps. Citation Text: Sutcliffe K, Lewton E, Rosenthal M. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79(2):186-194. Copy Citation Format:…

7902. Wrong site surgery near misses and actual occurrences. | PSNet
      psnet.ahrq.gov/issue/wrong-site-surgery-near-misses-and-actual-occurrences
      November 30, 2012 - Study Wrong site surgery near misses and actual occurrences. Citation Text: Blanco M, Clarke JR, Martindell D. Wrong site surgery near misses and actual occurrences. AORN J. 2009;90(2):215-8, 221-2. doi:10.1016/j.aorn.2009.07.010. Copy Citation Format: DOI Google Scholar …

7903. 'Failing wisely' can promote a safer healthcare system. | PSNet
      psnet.ahrq.gov/issue/failing-wisely-can-promote-safer-healthcare-system
      April 30, 2014 - Newspaper/Magazine Article 'Failing wisely' can promote a safer healthcare system. Citation Text: Fleisher LA, Edmondson AC. 'Failing wisely' can promote a safer healthcare system. MedPage Today. September 17, 2024; Copy Citation Format: Google Scholar BibTeX EndNote X3 XML…

7904. Risks related to patient bed safety. | PSNet
      psnet.ahrq.gov/issue/risks-related-patient-bed-safety
      July 19, 2023 - Commentary Risks related to patient bed safety. Citation Text: Sharkey JE, Van Leuven K, Radovich P. Risks related to patient bed safety. J Nurs Care Qual. 2012;27(4):346-51. doi:10.1097/NCQ.0b013e318264744b. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X…

7905. Principles of pediatric patient safety: reducing harm due to medical care. | PSNet
      psnet.ahrq.gov/issue/principles-pediatric-patient-safety-reducing-harm-due-medical-care
      May 22, 2019 - Organizational Policy/Guidelines Principles of pediatric patient safety: reducing harm due to medical care. Citation Text: Mueller BU, Neuspiel DR, Fisher ERS, et al. Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care. Pediatrics. 2019;143(2):e20183649. doi:10.1542…

7906. Do medication samples jeopardize patient safety? | PSNet
      psnet.ahrq.gov/issue/do-medication-samples-jeopardize-patient-safety
      November 16, 2022 - Study Do medication samples jeopardize patient safety? Citation Text: Franks AS, Ray S' M, Wallace LS, et al. Do medication samples jeopardize patient safety? Ann Pharmacother. 2009;43(1):51-6. doi:10.1345/aph.1L362. Copy Citation Format: DOI Google Scholar PubMed BibTeX …

7907. Finding blunders in thyroid testing: experience in newborns. | PSNet
      psnet.ahrq.gov/issue/finding-blunders-thyroid-testing-experience-newborns
      March 04, 2020 - Study Finding blunders in thyroid testing: experience in newborns. Citation Text: Zilka LJ, Lott JA, Baker LC, et al. Finding blunders in thyroid testing: experience in newborns. J Clin Lab Anal. 2008;22(4):254-6. doi:10.1002/jcla.20247. Copy Citation Format: DOI Google S…

7908. Strategies for developing and recognizing faculty working in quality improvement and patient safety. | PSNet
      psnet.ahrq.gov/issue/strategies-developing-and-recognizing-faculty-working-quality-improvement-and-patient-safety
      June 28, 2023 - Commentary Strategies for developing and recognizing faculty working in quality improvement and patient safety. Citation Text: Coleman DL, Wardrop RM, Levinson WS, et al. Strategies for Developing and Recognizing Faculty Working in Quality Improvement and Patient Safety. Acad Med. 2017;9…

7909. A safety maturity model for technology-induced errors. | PSNet
      psnet.ahrq.gov/issue/safety-maturity-model-technology-induced-errors
      June 15, 2022 - Review A safety maturity model for technology-induced errors. Citation Text: Borycki EM, Kushniruk AW. A safety maturity model for technology-induced errors. Stud Health Technol Inform. 2022;289:447-451. doi:10.3233/shti210954. Copy Citation Format: DOI Google Scholar BibTe…

7910. In Conversation With... Elsabeth Kalenderian, DDS, MPH, PhD and Muhammad F. Walji, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-walji-phd
      December 22, 2020 - In Conversation With... Elsabeth Kalenderian, DDS, MPH, PhD and Muhammad F. Walji, PhD December 22, 2020  Also Read the Essay Citation Text: In Conversation With.. Elsabeth Kalenderian, DDS, MPH, PhD and Muhammad F. Walji, PhD. PSNet [internet]. 2020.In Conversati…

7911. Adverse Events in Dentistry | PSNet
      psnet.ahrq.gov/perspective/adverse-events-dentistry
      December 22, 2020 - Adverse Events in Dentistry December 22, 2020  Also Read the Conversation View more articles from the same authors. Citation Text: Kalenderian E, Walji MF, Fitall E, et al. Adverse Events in Dentistry. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

7912. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50931/psn-pdf
      February 26, 2020 - Timely diagnosis of esophageal perforation February 26, 2020 Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation The Case  A man with mixed connective tissue disease on low-dose prednisone and methotrexate pre…

7913. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49420/psn-pdf
      October 01, 2003 - To LP or Not LP October 1, 2003 Landrigan CP. To LP or Not LP. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lp-or-not-lp The Case A 4-month-old male infant was seen in the office setting of a large multisite practice. He presented with fever and irritability without an obvious source. He was referred to …

7914. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33749/psn-pdf
      April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety? April 1, 2013 Fletcher KE, Reed DA. Are Residency Duty Hour Rules Improving Patient Safety? PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety Perspective Introduction The Accreditation Council f…

7915. Topics | PSNet
      psnet.ahrq.gov/topics-0
      March 03, 2025 - Topics Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts. Featured Topics in Patient Safety Updated Date: March 3, 2025 …

7916. Fatigue, Sleep Deprivation, and Patient Safety | PSNet
      psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety
      September 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety Citation Text: Fatigue, Sleep Deprivation, and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

7917. Healthcare-associated Infections | PSNet
      psnet.ahrq.gov/primer/health-care-associated-infections
      December 15, 2024 - Healthcare-associated Infections Citation Text: Healthcare - Associated Infections. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

7918. In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
      March 30, 2020 - safety culture; teamwork and team training; clinical decision support; person and family engagement; cultural

7919. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867497/psn-pdf
      February 26, 2025 - This problem is called normalization of deviance and may drive unhealthy cultural responses (e.g., “

7920. In Conversation With… Linda Aiken, PhD, RN | PSNet
      psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
      March 01, 2018 - In Conversation With… Linda Aiken, PhD, RN March 1, 2018  Also Read an Essay Citation Text: In Conversation With… Linda Aiken, PhD, RN. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …