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Missed breast cancer: effects of subconscious bias and lesion characteristics. | PSNet

psnet.ahrq.gov/issue/missed-breast-cancer-effects-subconscious-bias-and-lesion-characteristics

February 02, 2022 - Commentary Missed breast cancer: effects of subconscious bias and lesion characteristics. Citation Text: Lamb LR, Mohallem Fonseca M, Verma R, et al. Missed breast cancer: effects of subconscious bias and lesion characteristics. RadioGraphics. 2020;40(4):941-960. doi:10.1148/rg.202019009…

Do no harm: is it time to rethink the Hippocratic Oath? | PSNet

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May 04, 2022 - Commentary Do no harm: is it time to rethink the Hippocratic Oath? Citation Text: Walton M, Kerridge I. Do no harm: is it time to rethink the Hippocratic Oath? Med Educ. 2014;48(1):17-27. doi:10.1111/medu.12275. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNot…

The spectrum of harm associated with modern medicine. | PSNet

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July 26, 2023 - Commentary The spectrum of harm associated with modern medicine. Citation Text: Schattner A. The spectrum of harm associated with modern medicine. J Gen Intern Med. 2022;37(3):664-667. doi:10.1007/s11606-021-06997-x. Copy Citation Format: DOI Google Scholar BibTeX EndNote X…

General practitioners' attitudes toward reporting and learning from adverse events: results from a survey. | PSNet

psnet.ahrq.gov/issue/general-practitioners-attitudes-toward-reporting-and-learning-adverse-events-results-survey

September 13, 2023 - Study General practitioners' attitudes toward reporting and learning from adverse events: results from a survey. Citation Text: Mikkelsen TH, Sokolowski I, Olesen F. General practitioners' attitudes toward reporting and learning from adverse events: results from a survey. Scand J Prim …

A review of educational strategies to improve nurses' roles in recognizing and responding to deteriorating patients. | PSNet

psnet.ahrq.gov/issue/review-educational-strategies-improve-nurses-roles-recognizing-and-responding-deteriorating

October 16, 2013 - Review A review of educational strategies to improve nurses' roles in recognizing and responding to deteriorating patients. Citation Text: Liaw SY, Scherpbier A, Klainin-Yobas P, et al. A review of educational strategies to improve nurses' roles in recognizing and responding to deterio…

When doing wrong feels so right: normalization of deviance. | PSNet

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September 03, 2011 - Review When doing wrong feels so right: normalization of deviance. Citation Text: Price MR, Williams TC. When Doing Wrong Feels So Right: Normalization of Deviance. J Patient Saf. 2018;14(1):1-2. doi:10.1097/PTS.0000000000000157. Copy Citation Format: DOI Google Scholar Pub…

The end of the beginning: patient safety five years after 'To Err Is Human.' | PSNet

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March 02, 2011 - Commentary Classic The end of the beginning: patient safety five years after 'To Err Is Human.' Citation Text: Wachter RM. The End Of The Beginning: Patient Safety Five Years After ‘To Err Is Human’. Health Aff. 2004;23(Suppl1). doi:10.1377/hlthaff.w4.534. C…

Diagnostic heuristics in dermatology—part 1 and part 2. | PSNet

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June 24, 2010 - Review Diagnostic heuristics in dermatology—part 1 and part 2. Citation Text: Lowenstein EJ, Sidlow R. Cognitive and visual diagnostic errors in dermatology: part 1 and part 2. J Dermatol. 2018;179(6):1263-1276. doi:10.1111/bjd.16932. Copy Citation Format: DOI Google Schola…

Understanding ultrarare adverse events - lessons learned from a twelve-year review of intraoperative deaths at an academic medical center. | PSNet

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March 29, 2023 - Review Understanding ultrarare adverse events - lessons learned from a twelve-year review of intraoperative deaths at an academic medical center. Citation Text: Cohen TN, Kanji FF, Wang AS, et al. Understanding ultrarare adverse events - lessons learned from a twelve-year review of intra…

Clinical and pathological disagreement upon the cause of death in a teaching hospital: analysis of 100 autopsy cases in a prospective study. | PSNet

psnet.ahrq.gov/issue/clinical-and-pathological-disagreement-upon-cause-death-teaching-hospital-analysis-100

March 09, 2022 - Study Clinical and pathological disagreement upon the cause of death in a teaching hospital: analysis of 100 autopsy cases in a prospective study. Citation Text: Pinto Carvalho FL, Cordeiro JA, Cury PM. Clinical and pathological disagreement upon the cause of death in a teaching hospi…

Adverse Events in Hospitals: State Reporting Systems. | PSNet

psnet.ahrq.gov/issue/adverse-events-hospitals-state-reporting-systems

January 14, 2009 - Book/Report Adverse Events in Hospitals: State Reporting Systems. Citation Text: Adverse Events in Hospitals: State Reporting Systems. Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00471. …

Preventing blood transfusion failures: FMEA, an effective assessment method. | PSNet

psnet.ahrq.gov/issue/preventing-blood-transfusion-failures-fmea-effective-assessment-method

August 25, 2021 - Study Preventing blood transfusion failures: FMEA, an effective assessment method. Citation Text: Najafpour Z, Hasoumi M, Behzadi F, et al. Preventing blood transfusion failures: FMEA, an effective assessment method. BMC Health Serv Res. 2017;17(1):453. doi:10.1186/s12913-017-2380-3. C…

Transferring aviation practices into clinical medicine for the promotion of high reliability. | PSNet

psnet.ahrq.gov/issue/transferring-aviation-practices-clinical-medicine-promotion-high-reliability

September 12, 2018 - Review Transferring aviation practices into clinical medicine for the promotion of high reliability. Citation Text: Powell-Dunford N, McPherson MK, Pina JS, et al. Transferring Aviation Practices into Clinical Medicine for the Promotion of High Reliability. Aerosp Med Hum Perform. 2017;8…

Human factors and simulation in emergency medicine. | PSNet

psnet.ahrq.gov/issue/human-factors-and-simulation-emergency-medicine

November 16, 2022 - Commentary Human factors and simulation in emergency medicine. Citation Text: Hayden EM, Wong AH, Ackerman J, et al. Human Factors and Simulation in Emergency Medicine. Acad Emerg Med. 2018;25(2):221-229. doi:10.1111/acem.13315. Copy Citation Format: DOI Google Scholar PubM…

Creating a culture of safety around bar-code medication administration: an evidence-based evaluation framework. | PSNet

psnet.ahrq.gov/issue/creating-culture-safety-around-bar-code-medication-administration-evidence-based-evaluation

July 14, 2010 - Commentary Creating a culture of safety around bar-code medication administration: an evidence-based evaluation framework. Citation Text: Kelly K, Harrington L, Matos P, et al. Creating a Culture of Safety Around Bar-Code Medication Administration: An Evidence-Based Evaluation Framework.…

Canadian Association of University Surgeons' Annual Symposium. Surgical simulation: the solution to safe training or a promise unfulfilled? | PSNet

psnet.ahrq.gov/issue/canadian-association-university-surgeons-annual-symposium-surgical-simulation-solution-safe

March 09, 2022 - Review Canadian Association of University Surgeons' Annual Symposium. Surgical simulation: the solution to safe training or a promise unfulfilled? Citation Text: Brindley PG, Jones DB, Grantcharov T, et al. Canadian Association of University Surgeons' Annual Symposium. Surgical simulat…

How to mitigate the effects of cognitive biases during patient safety incident investigations. | PSNet

psnet.ahrq.gov/issue/how-mitigate-effects-cognitive-biases-during-patient-safety-incident-investigations

June 29, 2022 - Commentary How to mitigate the effects of cognitive biases during patient safety incident investigations. Citation Text: Rogers JE, Hilgers TR, Keebler JR, et al. How to mitigate the effects of cognitive biases during patient safety incident investigations. Jt Comm J Qual Patient Saf. 20…

Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine. | PSNet

psnet.ahrq.gov/issue/epidural-pump-programming-error-leading-inadvertent-10-fold-dosing-error-during-epidural

May 13, 2009 - Commentary Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine. Citation Text: Thyen AB, McAllister RK, Councilman LM. Epidural Pump Programming Error Leading to Inadvertent 10-Fold Dosing Error During Epidural La…

Time out! Rethinking surgical safety: more than just a checklist. | PSNet

psnet.ahrq.gov/issue/time-out-rethinking-surgical-safety-more-just-checklist

April 27, 2022 - Commentary Time out! Rethinking surgical safety: more than just a checklist. Citation Text: Weinger MB. Time out! Rethinking surgical safety: more than just a checklist. BMJ Qual Saf. 2021;30(8):613-617. doi:10.1136/bmjqs-2020-012600. Copy Citation Format: DOI Google Schola…

Engineering a safe landing: engaging medical practitioners in a systems approach to patient safety. | PSNet

psnet.ahrq.gov/issue/engineering-safe-landing-engaging-medical-practitioners-systems-approach-patient-safety

July 23, 2008 - Study Engineering a safe landing: engaging medical practitioners in a systems approach to patient safety. Citation Text: Brand C, Ibrahim JE, Bain C, et al. Engineering a safe landing: engaging medical practitioners in a systems approach to patient safety. Intern Med J. 2007;37(5):295-…

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