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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34654/psn-pdfJune 16, 2011 - Risk mitigation in large scale systems: lessons from high reliability organizations. June 16, 2011 Grabowski M, Roberts K. Calif Manag Rev. 1997;39(4):152-161. https://psnet.ahrq.gov/issue/risk-mitigation-large-scale-systems-lessons-high-reliability-organizations The authors examine high-reliability organizations,… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42994/psn-pdfMarch 26, 2014 - Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety. March 26, 2014 Renkema E, Broekhuis M, Ahaus K. Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety. BMC Health Serv Res. 2014;14:38… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/865527/psn-pdfApril 10, 2024 - Teamwork matters: team situation awareness to build high-performing healthcare teams, a narrative review. April 10, 2024 Weller JM, Mahajan R, Fahey-Williams K, et al. Teamwork matters: team situation awareness to build high- performing healthcare teams, a narrative review. Br J Anaesth. 2024;132(4):771-778. doi:1… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60575/psn-pdfJune 10, 2020 - Applying principles from aviation safety investigations to root cause analysis of a critical incident during a simulated emergency. June 10, 2020 Imach S, Eppich W, Zech A, et al. Applying principles from aviation safety investigations to root cause analysis of a critical incident during a simulated emergency. Sim… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50829/psn-pdfJanuary 22, 2020 - How one medical checkup can snowball into a ‘cascade’ of tests, causing more harm than good. January 22, 2020 Ganguli I. Washington Post. January 5, 2020. https://psnet.ahrq.gov/issue/how-one-medical-checkup-can-snowball-cascade-tests-causing-more-harm- good Overdiagnosis and uncertainty can result in a range of … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43172/psn-pdfMay 14, 2014 - Clinical clerkship students' perceptions of (un)safe transitions for every patient. May 14, 2014 Koch PE, Simpson D, Toth H, et al. Clinical Clerkship Students’ Perceptions of (Un)Safe Transitions for Every Patient. Academic Medicine. 2014;89(3). doi:10.1097/acm.0000000000000153. https://psnet.ahrq.gov/issue/clini… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60630/psn-pdfJune 24, 2020 - Education is “predictably disappointing” and should never be relied upon alone to improve safety. June 24, 2020 ISMP Medication Safety Alert! Acute care edition. June 4, 2020;25(11):1-4. https://psnet.ahrq.gov/issue/education-predictably-disappointing-and-should-never-be-relied-upon-alone- improve-safety Interven… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72725/psn-pdfFebruary 10, 2021 - Understanding the peer, manager, and system influence on patient safety. February 10, 2021 Forbes TH, Wynn J, Anderson T, et al. Understanding the peer, manager, and system influence on patient safety. Nurs Manage. 2020;51(12):36-42. doi:10.1097/01.numa.0000721828.72471.4a. https://psnet.ahrq.gov/issue/understandi… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45262/psn-pdfApril 01, 2021 - Each Baby Counts. April 1, 2021 Royal College of Obstetricians and Gynaecologists. https://psnet.ahrq.gov/issue/each-baby-counts-key-messages-2015 This organization highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38333/psn-pdfJanuary 14, 2009 - Adverse Events in Hospitals: Overview of Key Issues. January 14, 2009 Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470. https://psnet.ahrq.gov/issue/adverse-events-hospitals-overview-key-issues The Tax Relief and Hea… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45625/psn-pdfNovember 01, 2017 - Building comprehensive strategies for obstetric safety: simulation drills and communication. November 1, 2017 Austin N, Goldhaber-Fiebert SN, Daniels K, et al. Building Comprehensive Strategies for Obstetric Safety: Simulation Drills and Communication. Anesth Analg. 2016;123(5):1181-1190. https://psnet.ahrq.gov/is… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44868/psn-pdfJune 17, 2016 - Patient safety and the problem of many hands. June 17, 2016 Dixon-Woods M, Pronovost P. Patient safety and the problem of many hands. BMJ Qual Saf. 2016;25(7):485-488. doi:10.1136/bmjqs-2016-005232. https://psnet.ahrq.gov/issue/patient-safety-and-problem-many-hands Although individual and organizational accountabi… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43881/psn-pdfFebruary 11, 2015 - Cognitive Systems Engineering in Health Care. February 11, 2015 Bisantz AM, Burns CM, Fairbanks RJ, eds. Boca Raton, FL: CRC Press; 2014. ISBN: 9781466587960. https://psnet.ahrq.gov/issue/cognitive-systems-engineering-health-care This publication provides information about the role of cognition in medical error. Th… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38046/psn-pdfSeptember 10, 2008 - Clinical and pathological disagreement upon the cause of death in a teaching hospital: analysis of 100 autopsy cases in a prospective study. September 10, 2008 Pinto Carvalho FL, Cordeiro JA, Cury PM. Clinical and pathological disagreement upon the cause of death in a teaching hospital: Analysis of 100 autopsy cas… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39331/psn-pdfMarch 03, 2010 - Meta-analysis: effect of interactive communication between collaborating primary care physicians and specialists. March 3, 2010 Foy R, Hempel S, Rubenstein L, et al. Meta-analysis: effect of interactive communication between collaborating primary care physicians and specialists. Ann Intern Med. 2010;152(4):247-58.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/867020/psn-pdfOctober 23, 2024 - What can we learn from coroners’ reports on preventable deaths? October 23, 2024 Jeraj S. What can we learn from coroners’ reports on preventable deaths? BMJ. 2024;386:q1943. https://psnet.ahrq.gov/issue/what-can-we-learn-coroners-reports-preventable-deaths Analysis of system failure is only the beginning of the i… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41466/psn-pdfJune 20, 2012 - Factors predicting change in hospital safety climate and capability in a multi-site patient safety collaborative: a longitudinal survey study. June 20, 2012 Benn J, Burnett S, Parand A, et al. Factors predicting change in hospital safety climate and capability in a multi-site patient safety collaborative: a longit… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44465/psn-pdfNovember 20, 2015 - Why even good physicians do not wash their hands. November 20, 2015 Redelmeier DA, Shafir E. Why even good physicians do not wash their hands. BMJ Qual Saf. 2015;24(12):744-7. doi:10.1136/bmjqs-2015-004319. https://psnet.ahrq.gov/issue/why-even-good-physicians-do-not-wash-their-hands Insufficient hand hygiene comp… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/865880/psn-pdfMay 15, 2024 - Racial and ethnic harm in patient care is a patient safety issue. May 15, 2024 Rosario N, Kiles TM, M. Jewell T'B, et al. Racial and ethnic harm in patient care is a patient safety issue. Res Social Adm Pharm. 2024;20(7):670-677. doi:10.1016/j.sapharm.2024.04.012. https://psnet.ahrq.gov/issue/racial-and-ethnic-har… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866963/psn-pdfOctober 16, 2024 - FDA’s promised guidance on pulse oximeters unlikely to end decades of racial bias. October 16, 2024 Allen A. FDA’s promised guidance on pulse oximeters unlikely to end decades of racial bias. KFF Health News. October 07, 2024; https://psnet.ahrq.gov/issue/fdas-promised-guidance-pulse-oximeters-unlikely-end-decades…
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