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461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49726/psn-pdf
     March 01, 2015 - Definitions and Examples of Wrong-Site Surgeries.(2) Type Definition Example Wrong Site All surgical

462. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40769/psn-pdf
     March 21, 2012 - Identification of adverse events in ground transport emergency medical services. March 21, 2012 Patterson PD, Weaver MD, Abebe K, et al. Identification of adverse events in ground transport emergency medical services. Am J Med Qual. 2011;27(2):139-146. doi:10.1177/1062860611415515. https://psnet.ahrq.gov/issue/ide…

463. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34648/psn-pdf
     April 21, 2015 - Gaps in the continuity of care and progress on patient safety. April 21, 2015 Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ. 2000;320(7237):791-4. https://psnet.ahrq.gov/issue/gaps-continuity-care-and-progress-patient-safety This commentary discusses the concept o…

464. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40883/psn-pdf
     February 10, 2012 - Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology. February 10, 2012 Nakhleh RE, Myers JL, Allen TC, et al. Conse…

465. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38945/psn-pdf
     November 25, 2009 - The negative impact of nurse-physician disruptive behavior on patient safety: a review of the literature. November 25, 2009 Saxton R, Hines T, Enriquez M. The negative impact of nurse-physician disruptive behavior on patient safety: a review of the literature. J Patient Saf. 2009;5(3):180-183. doi:10.1097/pts.0b013…

466. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36335/psn-pdf
     February 01, 2011 - Rapid response teams—walk, don't run. February 1, 2011 Winters BD, Pham JC, Pronovost PJ. Rapid Response Teams—Walk, Don't Run. JAMA. 2006;296(13). doi:10.1001/jama.296.13.1645. https://psnet.ahrq.gov/issue/rapid-response-teams-walk-dont-run Rapid response teams (RRTs) have been widely advocated as a means of aver…

467. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43473/psn-pdf
     August 27, 2014 - Rapid response team implementation and in-hospital mortality. August 27, 2014 Salvatierra G, Bindler RC, Corbett CF, et al. Rapid response team implementation and in-hospital mortality*. Crit Care Med. 2014;42(9):2001-6. doi:10.1097/CCM.0000000000000347. https://psnet.ahrq.gov/issue/rapid-response-team-implementat…

468. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41406/psn-pdf
     August 02, 2012 - Can patients report patient safety incidents in a hospital setting? A systematic review. August 2, 2012 Ward JK, Armitage G. Can patients report patient safety incidents in a hospital setting? A systematic review. BMJ Qual Saf. 2012;21(8):685-99. doi:10.1136/bmjqs-2011-000213. https://psnet.ahrq.gov/issue/can-pati…

469. Lethal Vertigo | PSNet
     psnet.ahrq.gov/web-mm/lethal-vertigo
     September 20, 2011 - Lethal Vertigo Citation Text: Furman JM. Lethal Vertigo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60299/psn-pdf
     May 06, 2020 - Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy. May 6, 2020 Franklin BJ, Gandhi TK, Bates DW, et al. Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy. BMJ Qual Saf. 2020;29(10):844–853. doi:10.1136/bmjqs-2019…

471. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61066/psn-pdf
     October 28, 2020 - Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic. October 28, 2020 Kasda EM, Robson C, Saunders J, et al. Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic. J Patient Saf Risk Manag. 2020;25(4)…

472. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73087/psn-pdf
     March 31, 2021 - Developing open disclosure strategies to medical error using simulation in final-year medical students: linking mindset and experiential learning to lifelong reflective practice. March 31, 2021 Lane AS, Roberts C. Developing open disclosure strategies to medical error using simulation in final-year medical studen…

473. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47834/psn-pdf
     February 27, 2019 - Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. February 27, 2019 Rhee C, Jones TM, Hamad Y, et al. Prevalence, Underlying Causes, and Preventability of Sepsis- Associated Mortality in US Acute Care Hospitals. JAMA Netw Open. 2019;2(2):e187571. doi:10.10…

474. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/764398/psn-pdf
     March 02, 2022 - What do we really know about crew resource management in healthcare?: An umbrella review on crew resource management and its effectiveness. March 2, 2022 Buljac-Samardzic M, Dekker-van Doorn CM, Maynard MT. What do we really know about crew resource management in healthcare?: An umbrella review on crew resource ma…

475. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46380/psn-pdf
     September 06, 2017 - What defines a high-performing health system: a systematic review. September 6, 2017 Ahluwalia SC, Damberg CL, Silverman M, et al. What Defines a High-Performing Health Care Delivery System: A Systematic Review. Jt Comm J Qual Patient Saf. 2017;43(9):450-459. doi:10.1016/j.jcjq.2017.03.010. https://psnet.ahrq.gov…

476. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47039/psn-pdf
     September 12, 2018 - Overdiagnosis in primary care: framing the problem and finding solutions. September 12, 2018 Kale MS, Korenstein D. Overdiagnosis in primary care: framing the problem and finding solutions. BMJ. 2018;362:k2820. doi:10.1136/bmj.k2820. https://psnet.ahrq.gov/issue/overdiagnosis-primary-care-framing-problem-and-findi…

477. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50914/psn-pdf
     February 19, 2020 - Uncovering, creating or constructing problems? Enacting a new role to support staff who raise concerns about quality and safety in the English National Health Service February 19, 2020 Martin GP, Chew S, Dixon-Woods M. Uncovering, creating or constructing problems? Enacting a new role to support staff who raise co…

478. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47278/psn-pdf
     August 15, 2018 - Drawing boundaries: the difficulty in defining clinical reasoning. August 15, 2018 Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning. Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0000000000002142. https://psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defi…

479. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45504/psn-pdf
     January 01, 2018 - Hospital nurses' work environment characteristics and patient safety outcomes: a literature review. December 16, 2017 Lee SE, Scott LD. Hospital Nurses' Work Environment Characteristics and Patient Safety Outcomes: A Literature Review. West J Nurs Res. 2018;40(1):121-145. doi:10.1177/0193945916666071. https://psne…

480. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44335/psn-pdf
     July 16, 2015 - Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare. July 16, 2015 Van Spall H, Kassam A, Tollefson TT. Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare. Curr Opin …