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1701. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41850/psn-pdf
      November 21, 2012 - TeamSTEPPS: the patient safety tool that needs to be implemented. November 21, 2012 Clapper TC, Kong M. TeamSTEPPS®: The Patient Safety Tool That Needs to Be Implemented. Clin Simul Nurs. 2011;8(8). doi:10.1016/j.ecns.2011.03.002. https://psnet.ahrq.gov/issue/teamstepps-patient-safety-tool-needs-be-implemented De…

1702. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45663/psn-pdf
      November 09, 2016 - Nursing Home Antimicrobial Stewardship Guide. November 9, 2016 Rockville, MD: Agency for Healthcare Research and Quality; October 2016. https://psnet.ahrq.gov/issue/nursing-home-antimicrobial-stewardship-guide Antimicrobial stewardship is one strategy to reduce health care–associated infections in a variety of set…

1703. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36464/psn-pdf
      January 07, 2011 - Establishing a rapid response team (RRT) in an academic hospital: one year's experience. January 7, 2011 King E, Horvath R, Shulkin DJ. Establishing a rapid response team (RRT) in an academic hospital: One year's experience. J Hosp Med. 2006;1(5). doi:10.1002/jhm.114. https://psnet.ahrq.gov/issue/establishing-rapi…

1704. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41407/psn-pdf
      June 19, 2012 - Error disclosure: a new domain for safety culture assessment. June 19, 2012 Etchegaray J, Gallagher TH, Bell SK, et al. Error disclosure: a new domain for safety culture assessment. BMJ Qual Saf. 2012;21(7):594-9. doi:10.1136/bmjqs-2011-000530. https://psnet.ahrq.gov/issue/error-disclosure-new-domain-safety-cultur…

1705. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40464/psn-pdf
      June 10, 2018 - Multiple latent failures align to allow a serious drug interaction to harm a patient. June 10, 2018 ISMP Medication Safety Alert! Acute care edition. May 5, 2011;16:1-3. https://psnet.ahrq.gov/issue/multiple-latent-failures-align-allow-serious-drug-interaction-harm-patient Detailing a case in which latent failures…

1706. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37758/psn-pdf
      March 10, 2011 - Informatics opportunities: the intersection of patient safety and clinical informatics. March 10, 2011 Kilbridge PM, Classen D. The informatics opportunities at the intersection of patient safety and clinical informatics. J Am Med Inform Assoc. 2008;15(4):397-407. doi:10.1197/jamia.M2735. https://psnet.ahrq.gov/is…

1707. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34782/psn-pdf
      November 01, 2016 - When systems fail. November 1, 2016 Roberts KH, Bea RG. When systems fail. Organ Dyn. 2002;29(3):179-191. doi:10.1016/s0090- 2616(01)00025-0. https://psnet.ahrq.gov/issue/when-systems-fail This review provides a detailed account of managerial causes of failure and managerial failure prevention strategies. The aut…

1708. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49800/psn-pdf
      July 01, 2017 - The Hidden Harms of Hand Sanitizer July 1, 2017 Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer The Case A 57-year-old woman with a history of alcohol abuse and severe depression was admitted to the hospital for community-acquired pn…

1709. Health Care Data Science for Quality Improvement and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
      October 01, 2016 - trail of data showing every step in which multiple health care professionals took care of countless details … medications, but I soon realized that I only initiated a Rube Goldberg–like machine that handled all the details … work productively with biostatisticians, clinician data scientists should know enough of the technical details

1710. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33922/psn-pdf
      August 05, 2009 - The importance of cognitive errors in diagnosis and strategies to minimize them. August 5, 2009 Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780. https://psnet.ahrq.gov/issue/importance-cognitive-errors-diagnosis-and-strategies-minimize-them…

1711. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35547/psn-pdf
      March 02, 2010 - Use of the common gas outlet for supplementary oxygen during Caesarean section. March 2, 2010 Edsell MEG, Erasmus PD. Use of the common gas outlet for supplementary oxygen during Caesarean section. Anaesthesia. 2005;60(11):1152-3. https://psnet.ahrq.gov/issue/use-common-gas-outlet-supplementary-oxygen-during-caesa…

1712. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34790/psn-pdf
      December 23, 2008 - Cognitive errors in diagnosis: instantiation, classification, and consequences. December 23, 2008 Kassirer JP, Kopelman RI. Cognitive errors in diagnosis: instantiation, classification, and consequences. Am J Med. 1989;86(4):433-41. https://psnet.ahrq.gov/issue/cognitive-errors-diagnosis-instantiation-classificati…

1713. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35254/psn-pdf
      April 06, 2011 - Adverse events and near miss reporting in the NHS. April 6, 2011 Shaw R. Adverse events and near miss reporting in the NHS. Quality and Safety in Health Care. 2005;14(4). doi:10.1136/qshc.2004.010553. https://psnet.ahrq.gov/issue/adverse-events-and-near-miss-reporting-nhs This study evaluated the utility of a volu…

1714. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34816/psn-pdf
      February 28, 2018 - Blaming others for threatening events. February 28, 2018 Tennen H; Affleck G. https://psnet.ahrq.gov/issue/blaming-others-threatening-events This detailed review summarizes existing evidence on how people adapt to threatening events by blaming others. Discussion includes a synthesis of past work and explanations f…

1715. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34757/psn-pdf
      November 18, 2015 - Unity of Mistakes: A Phenomenological Interpretation of Medical Work. November 18, 2015 Paget MA. Philadelphia: Temple University Press; 2004. https://psnet.ahrq.gov/issue/unity-mistakes-phenomenological-interpretation-medical-work In this often described landmark text on the nature of medical error, Marianne Page…

1716. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35193/psn-pdf
      July 10, 2008 - Diagnostic error in internal medicine. July 10, 2008 Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499. https://psnet.ahrq.gov/issue/diagnostic-error-internal-medicine This study identified 100 cases of diagnostic error in internal medicine and conducte…

1717. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34798/psn-pdf
      June 23, 2015 - Costs of medical injuries in Utah and Colorado. June 23, 2015 Thomas EJ; Studdert DM; Newhouse JP; Zbar BI; Howard KM; Williams EJ; Brennan TA https://psnet.ahrq.gov/issue/costs-medical-injuries-utah-and-colorado This study analyzed more than 450 adverse events from a representative hospital sample in order to est…

1718. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42153/psn-pdf
      April 03, 2013 - Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emergency department network. April 3, 2013 Chamberlain JM, Shaw KN, Lillis KA, et al. Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emergency department network. Pediatr Em…

1719. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43654/psn-pdf
      April 02, 2015 - Nursing bedside clinical handover—an integrated review of issues and tools. April 2, 2015 Anderson J, Malone L, Shanahan K, et al. Nursing bedside clinical handover - an integrated review of issues and tools. J Clin Nurs. 2015;24(5-6):662-671. doi:10.1111/jocn.12706. https://psnet.ahrq.gov/issue/nursing-bedside-cl…

1720. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39876/psn-pdf
      July 02, 2014 - The anatomy of health care team training and the state of practice: a critical review. July 2, 2014 Weaver SJ, Lyons R, DiazGranados D, et al. The anatomy of health care team training and the state of practice: a critical review. Acad Med. 2010;85(11):1746-60. doi:10.1097/ACM.0b013e3181f2e907. https://psnet.ahrq.g…