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421. Workaround | PSNet
     psnet.ahrq.gov/taxonomy/term/3504
     June 24, 2025 - Workaround From the perspective of frontline personnel trying to accomplish their work, the design of equipment or the policies governing work tasks can seem counterproductive. When frontline personnel adopt consistent patterns of work or ways of bypassing safety features of medical equipment, these patterns and acti…

422. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866281/psn-pdf
     July 10, 2024 - Updating Eindhoven: clarifying the features of a patient safety near miss. July 10, 2024 Woodier N, Burnett C, Sampson P, et al. Updating Eindhoven: clarifying the features of a patient safety near miss. J Patient Saf Risk Manag. 2024;29(4):195-201. doi:10.1177/25160435241247096. https://psnet.ahrq.gov/issue/updat…

423. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866809/psn-pdf
     September 25, 2024 - Stop the line: interventions to prevent retained surgical items. September 25, 2024 Angelilli S. Stop the line: interventions to prevent retained surgical items. AORN J. 2024;120(2):71-81. doi:10.1002/aorn.14190. https://psnet.ahrq.gov/issue/stop-line-interventions-prevent-retained-surgical-items Retained surgica…

424. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73896/psn-pdf
     September 29, 2021 - Policies to promote shared responsibility for safer electronic health records. September 29, 2021 Sittig DF, Singh H. Policies to promote shared responsibility for safer electronic health records. JAMA. 2021;326(15):1477-1478. doi:10.1001/jama.2021.13945. https://psnet.ahrq.gov/issue/policies-promote-shared-respon…

425. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47936/psn-pdf
     June 14, 2019 - A team disclosure of error educational activity: objective outcomes. June 14, 2019 Krumwiede KH, Wagner JM, Kirk LM, et al. A Team Disclosure of Error Educational Activity: Objective Outcomes. J Am Geriatr Soc. 2019;67(6):1273-1277. doi:10.1111/jgs.15883. https://psnet.ahrq.gov/issue/team-disclosure-error-educatio…

426. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866557/psn-pdf
     August 21, 2024 - Minimization of occurrence of retained surgical items using machine learning and deep learning techniques: a review. August 21, 2024 Abo-Zahhad M, El-Malek AHA, Sayed MS, et al. Minimization of occurrence of retained surgical items using machine learning and deep learning techniques: a review. BioData Min. 2024;17…

427. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33672/psn-pdf
     September 01, 2008 - In Conversation with…Eric G. Poon, MD, MPH September 1, 2008 In Conversation with…Eric G. Poon, MD, MPH. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph Editor's note: Eric G. Poon, MD, MPH, is Director of Clinical Informatics at Brigham and Women's Hospital and Assi…

428. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38233/psn-pdf
     March 03, 2010 - The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise. March 3, 2010 Kaji AH, Cone DC, eds. Acad Emerg Med. 2008;15:971-1222.   https://psnet.ahrq.gov/issue/science-simulation-healthcare-defining-and-developing-clinical-expertise This special issue highlights an AHRQ-funded sympo…

429. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35799/psn-pdf
     March 29, 2006 - The ethics and practical importance of defining, distinguishing and disclosing nursing errors: a discussion paper. March 29, 2006 Johnstone MJ; Kanitsaki O. https://psnet.ahrq.gov/issue/ethics-and-practical-importance-defining-distinguishing-and-disclosing-nursing- errors The authors provide a definition of "nur…

430. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866400/psn-pdf
     January 01, 2025 - Medication administration in aged care facilities: a mixed- methods systematic review. July 31, 2024 Garratt S, Dowling A, Manias E. Medication administration in aged care facilities: a mixed?methods systematic review. J Adv Nurs. 2025;81(2):621-640. doi:10.1111/jan.16318. https://psnet.ahrq.gov/issue/medication-a…

431. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866115/psn-pdf
     June 12, 2024 - Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review. June 12, 2024 Tsang JY, Sperrin M, Blakeman T, et al. Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review. BMJ Open. 2024;14(5):e0…

432. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/860732/psn-pdf
     April 16, 2024 - Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports. April 16, 2024 Dorset, UK: Health Services Safety Investigations Body; April 2024. https://psnet.ahrq.gov/issue/retained-swabs-following-invasive-procedures-themes-identified-review-nhs- serious-incident …

433. Error | PSNet
     psnet.ahrq.gov/taxonomy/term/3475
     June 09, 2025 - Error An act of commission (doing something wrong) or omission (failing to do the right thing) that leads to an undesirable outcome or significant potential for such an outcome. For instance, ordering a medication for a patient with a documented allergy to that medication would be an act of commission. Failing to pre…

434. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50827/psn-pdf
     January 22, 2020 - Becoming a high-reliability organization through shared learning of safety events January 22, 2020 Klenklen J. Patient Saf Qual HCare. December 19, 2019. https://psnet.ahrq.gov/issue/becoming-high-reliability-organization-through-shared-learning-safety-events High reliability organizations consistently examine wha…

435. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38497/psn-pdf
     July 13, 2009 - Social aspects of clinical errors: a discussion paper. July 13, 2009 Richman J, Mason T, Mason-Whitehead E, et al. Social aspects of clinical errors. Int J Nurs Stud. 2009;46(8). doi:10.1016/j.ijnurstu.2009.01.006. https://psnet.ahrq.gov/issue/social-aspects-clinical-errors-discussion-paper This article engages wi…

436. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35124/psn-pdf
     June 29, 2005 - JCAHO proposal for patient-centered care brings concept to mainstream healthcare settings. June 29, 2005 ECRI. Risk Management Reporter. June 2005. https://psnet.ahrq.gov/issue/jcaho-proposal-patient-centered-care-brings-concept-mainstream-healthcare- settings This commentary provides a definition of patient-cent…

437. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/858165/psn-pdf
     December 13, 2023 - When public health goes wrong: toward a new concept of public health error. December 13, 2023 Bavli I. When public health goes wrong: toward a new concept of public health error. J Law Med Ethics. 2023;51(2):385-402. doi:10.1017/jme.2023.67. https://psnet.ahrq.gov/issue/when-public-health-goes-wrong-toward-new-con…

438. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60322/psn-pdf
     May 13, 2020 - Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality. May 13, 2020 Leistikow I, Bal RA. Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality. BMJ Qual Saf. 2020;29(10):869–872. doi:10.113…

439. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46788/psn-pdf
     April 11, 2018 - Preventing newborn falls and drops. April 11, 2018 Quick Safety. March 27, 2018;(40):1-2. https://psnet.ahrq.gov/issue/preventing-newborn-falls-and-drops Falls are a common patient safety concern for adults but are rarely discussed as a threat to newborn safety. This newsletter article provides a definition for a …

440. PSNet Curated Library (pdf file)
     psnet.ahrq.gov/print/pdf/node/854855
     January 01, 2024 - Whether patient and family understanding of safety issues aligns with standard definitions of medical … Whether patient and family understanding of safety issues aligns with standard definitions of medical