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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
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
September 28, 2022 - In Conversation With... Jack Westfall, MD, MPH
September 28, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Jack Westfall, MD, MPH. PSNet [internet]. 2022.In Conversation With... Jack Westfall, MD, MPH. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - Primary Care and Patient Safety: Opportunities at the Interface
September 28, 2022
Also Read the Conversations
In Conversation With... Freya Spielberg, MD, MPH
In Conversation With... Jack Westfall, MD, MPH
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