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psnet.ahrq.gov/node/35832/psn-pdf
August 04, 2009 - The incorporation of patient safety into board certification
examinations.
August 4, 2009
Kachalia A, Johnson J, Miller ST, et al. The incorporation of patient safety into board certification
examinations. Acad Med. 2006;81(4):317-25.
https://psnet.ahrq.gov/issue/incorporation-patient-safety-board-certification-ex…
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psnet.ahrq.gov/node/34058/psn-pdf
September 29, 2017 - Research designs for studies evaluating the effectiveness
of change and improvement strategies.
September 29, 2017
Eccles M, Grimshaw J, Campbell M, et al. Research designs for studies evaluating the effectiveness of
change and improvement strategies. Qual Saf Health Care. 2003;12(1):47-52.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/34013/psn-pdf
December 22, 2008 - Defining and measuring patient safety.
December 22, 2008
Pronovost P, Thompson DA, Holzmueller CG, et al. Defining and measuring patient safety. Crit Care Clin.
2005;21(1):1-19, vii.
https://psnet.ahrq.gov/issue/defining-and-measuring-patient-safety
This review discusses the increasing demand for improving patient…
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psnet.ahrq.gov/node/43413/psn-pdf
October 20, 2014 - The morbidity and mortality conference as an adverse
event surveillance tool in a paediatric intensive care unit.
October 20, 2014
Cifra CL, Jones KL, Ascenzi J, et al. The morbidity and mortality conference as an adverse event
surveillance tool in a paediatric intensive care unit. BMJ Qual Saf. 2014;23(11):930-8. …
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psnet.ahrq.gov/node/49524/psn-pdf
November 01, 2006 - Secured But Not Always Safe
November 1, 2006
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/secured-not-always-safe
The Case
An 84-year-old healthy woman underwent an elective left total knee replacement for degenerative
osteoarthritis. She received spinal …
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psnet.ahrq.gov/node/35840/psn-pdf
May 27, 2011 - Development of the Leapfrog methodology for evaluating
hospital implemented inpatient computerized physician
order entry systems.
May 27, 2011
Kilbridge PM, Welebob EM, Classen DC. Development of the Leapfrog methodology for evaluating hospital
implemented inpatient computerized physician order entry systems. Qual…
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psnet.ahrq.gov/node/35748/psn-pdf
February 02, 2011 - Policies and practices related to the role of board
certification and recertification of pediatricians in hospital
privileging.
February 2, 2011
Freed GL, Uren RL, Hudson EJ, et al. Policies and practices related to the role of board certification and
recertification of pediatricians in hospital privileging. JAMA.…
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psnet.ahrq.gov/node/39709/psn-pdf
September 20, 2011 - A systems approach to morbidity and mortality
conference.
September 20, 2011
Szostek JH, Wieland ML, Loertscher LL, et al. A systems approach to morbidity and mortality conference.
Am J Med. 2010;123(7):663-668. doi:10.1016/j.amjmed.2010.03.010.
https://psnet.ahrq.gov/issue/systems-approach-morbidity-and-mortality…
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psnet.ahrq.gov/node/36007/psn-pdf
February 02, 2011 - A piece of my mind. Copy-and-paste.
February 2, 2011
Hirschtick RE. A piece of my mind. Copy-and-paste. JAMA. 2006;295(20):2335-6.
https://psnet.ahrq.gov/issue/piece-my-mind-copy-and-paste
While the impact on time efficiency and quality of ambulatory care has raised questions about the utility of
electronic health…
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psnet.ahrq.gov/node/35434/psn-pdf
June 14, 2011 - Turning the medical gaze in upon itself: root cause
analysis and the investigation of clinical error.
June 14, 2011
Iedema RAM, Jorm C, Long D, et al. Turning the medical gaze in upon itself: root cause analysis and the
investigation of clinical error. Soc Sci Med. 2006;62(7):1605-15.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/38731/psn-pdf
April 30, 2014 - Preventable morbidity at a mature trauma center.
April 30, 2014
Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144(6):536-541.
https://psnet.ahrq.gov/issue/preventable-morbidity-mature-trauma-center
Patient safety in trauma poses unique challenges given the acuity of the patients and the need for rapid
ass…
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psnet.ahrq.gov/node/49432/psn-pdf
February 09, 2004 - We now have monthly patient safety discussions at residents' report.
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psnet.ahrq.gov/node/49552/psn-pdf
January 01, 2008 - and therefore may place
providers at risk for public humiliation and shame.(11,14,22) However, if discussions
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psnet.ahrq.gov/issue/office-surgery-incidents-what-seven-years-florida-data-show-us
August 19, 2009 - Study
Office surgery incidents: what seven years of Florida data show us.
Citation Text:
Coldiron BM, Healy C, Bene NI. Office surgery incidents: what seven years of Florida data show us. Dermatol Surg. 2008;34(3):285-91; discussion 291-2. doi:10.1111/j.1524-4725.2007.34060.x.
Copy C…
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psnet.ahrq.gov/node/39691/psn-pdf
January 22, 2014 - Responsibility for quality improvement and patient safety:
hospital board and medical staff leadership challenges.
January 22, 2014
Goeschel CA, Wachter R, Pronovost P. Responsibility for quality improvement and patient safety: hospital
board and medical staff leadership challenges. Chest. 2010;138(1):171-8. doi:10…
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psnet.ahrq.gov/node/38570/psn-pdf
April 22, 2009 - Factors influencing incident reporting in surgical care.
April 22, 2009
Kreckler S, Catchpole K, McCulloch P, et al. Factors influencing incident reporting in surgical care. Qual
Saf Health Care. 2009;18(2):116-20. doi:10.1136/qshc.2008.026534.
https://psnet.ahrq.gov/issue/factors-influencing-incident-reporting-sur…
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psnet.ahrq.gov/web-mm/inadvertent-castration
October 27, 2010 - In subsequent discussions with both the patient and his wife about hormonal replacement, the patient
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psnet.ahrq.gov/web-mm/do-me-favor
September 12, 2016 - "( 4,6 ) Open discussions about appropriate types of caregiving among colleagues in institutions is a
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psnet.ahrq.gov/web-mm/after-visit-confusion
August 21, 2007 - They may also provide patients with tailored information relevant to the clinical discussions that occurred
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psnet.ahrq.gov/web-mm/cultural-dimensions-depression
September 01, 2018 - After this event, subsequent discussions with the family revealed some relevant details.