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psnet.ahrq.gov/issue/avoiding-wrong-site-surgery-systematic-review
October 19, 2022 - Review
Avoiding wrong site surgery: a systematic review.
Citation Text:
Devine J, Chutkan N, Norvell DC, et al. Avoiding wrong site surgery: a systematic review. Spine (Phila Pa 1976). 2010;35(9 Suppl):S28-36. doi:10.1097/BRS.0b013e3181d833ac.
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psnet.ahrq.gov/issue/surgical-accountability-1880s-death-susan-nixon
November 16, 2022 - Commentary
Surgical accountability in the 1880s: the death of Susan Nixon.
Citation Text:
Watters GR, Walker DR. Surgical accountability in the 1880s: the death of Susan Nixon. ANZ J Surg. 2005;75(8). doi:10.1111/j.1445-2197.2005.03501.x.
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psnet.ahrq.gov/issue/disclosing-adverse-events-patients
September 23, 2020 - Commentary
Disclosing adverse events to patients.
Citation Text:
Cantor MD, Barach P, Derse A, et al. Disclosing adverse events to patients. Jt Comm J Qual Patient Saf. 2005;31(1):5-12.
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psnet.ahrq.gov/issue/residents-responses-medical-error-coping-learning-and-change
August 03, 2009 - Study
Residents' responses to medical error: coping, learning, and change.
Citation Text:
Engel KG, Rosenthal M, Sutcliffe K. Residents' responses to medical error: coping, learning, and change. Acad Med. 2006;81(1):86-93.
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psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems-months-shutdown-then
July 18, 2018 - Newspaper/Magazine Article
Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go.
Citation Text:
Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. Massey W, Keith …
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psnet.ahrq.gov/issue/high-performance-teams-and-physician-leader-overview
December 14, 2016 - Commentary
High-performance teams and the physician leader: an overview.
Citation Text:
Majmudar A, Jain AK, Chaudry J, et al. High-performance teams and the physician leader: an overview. J Surg Educ. 2010;67(4):205-9. doi:10.1016/j.jsurg.2010.06.002.
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psnet.ahrq.gov/issue/why-dont-we-know-whether-care-safe
January 14, 2014 - Commentary
Why don't we know whether care is safe?
Citation Text:
Pham JC, Frick KD, Pronovost P. Why don't we know whether care is safe? Am J Med Qual. 2013;28(6):457-63. doi:10.1177/1062860613479397.
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psnet.ahrq.gov/issue/intrahospital-transport-radiology-department-risk-adverse-events-nursing-surveillance
September 04, 2013 - Commentary
Intrahospital transport to the radiology department: risk for adverse events, nursing surveillance, utilization of a MET and practice implications.
Citation Text:
Ott LK, Hoffman LA, Hravnak M. Intrahospital Transport to the Radiology Department: Risk for Adverse Events, Nur…
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digital.ahrq.gov/track-6-using-reporting-systems-safety-and-quality-improvement
January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…
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psnet.ahrq.gov/issue/factors-influencing-patient-safety-during-postoperative-handover
March 03, 2021 - Review
Factors influencing patient safety during postoperative handover.
Citation Text:
Factors influencing patient safety during postoperative handover. Rose M, Newman SD. AANA J. 2016;84:329-338.
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psnet.ahrq.gov/issue/effective-approaches-control-non-actionable-alarms-and-alarm-fatigue
January 15, 2025 - Commentary
Effective approaches to control non-actionable alarms and alarm fatigue.
Citation Text:
Winters BD. Effective approaches to control non-actionable alarms and alarm fatigue. J Electrocardiol. 2018;51(6S):S49-S51. doi:10.1016/j.jelectrocard.2018.07.007.
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psnet.ahrq.gov/issue/disclosing-unanticipated-outcomes-patients-art-and-practice
July 14, 2010 - Commentary
Disclosing unanticipated outcomes to patients: the art and practice.
Citation Text:
Disclosing unanticipated outcomes to patients: the art and practice. Gallagher TH; Denham CR; Leape LL; Amori G; Levinson W.
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psnet.ahrq.gov/issue/how-avoid-paediatric-medication-errors-users-guide-literature
May 26, 2011 - Review
How to avoid paediatric medication errors: a user's guide to the literature.
Citation Text:
Walsh KE, Kaushal R, Chessare JB. How to avoid paediatric medication errors: a user's guide to the literature. Arch Dis Child. 2005;90(7):698-702.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state2.html
January 01, 2024 - Current State of Diagnostic Safety: Implications for Research, Practice, and Policy
2. Methods
Previous Page Next Page
Table of Contents
Current State of Diagnostic Safety: Implications for Research, Practice, and Policy
1. Introduction
2. Methods
3. Results
4. Discussion
References
Appe…
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psnet.ahrq.gov/issue/misinformation-medical-literature-what-role-do-error-and-fraud-play
November 02, 2011 - Commentary
Misinformation in the medical literature: what role do error and fraud play?
Citation Text:
Steen G. Misinformation in the medical literature: what role do error and fraud play? J Med Ethics. 2011;37(8):498-503. doi:10.1136/jme.2010.041830.
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psnet.ahrq.gov/issue/special-section-iea-health-care-2021
August 02, 2010 - Special or Theme Issue
Special Section: IEA Health Care 2021.
Citation Text:
Special Section: IEA Health Care 2021. Hum Factors. 2024;66(3):633-769.
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psnet.ahrq.gov/issue/senators-threaten-consequences-after-va-confirms-4-deaths-tied-computer-system-tested-spokane
September 21, 2022 - Newspaper/Magazine Article
Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane.
Citation Text:
Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane. Donovan-Smith O. Spokesman Review. March 15,…
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psnet.ahrq.gov/issue/nearly-all-hospital-pharmacists-say-drug-shortages-are-negatively-impacting-care-third-say
September 15, 2021 - Newspaper/Magazine Article
Nearly all hospital pharmacists say drug shortages are negatively impacting care; a third say impacts are ‘critical.’
Citation Text:
Nearly all hospital pharmacists say drug shortages are negatively impacting care; a third say impacts are ‘critical.’ McPhillips…
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psnet.ahrq.gov/issue/emergency-physicians-and-disclosure-medical-errors
October 19, 2022 - Study
Emergency physicians and disclosure of medical errors.
Citation Text:
Moskop JC, Geiderman JM, Hobgood CD, et al. Emergency physicians and disclosure of medical errors. Ann Emerg Med. 2006;48(5):523-31.
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psnet.ahrq.gov/issue/physician-autonomy-and-informed-decision-making-finding-balance-patient-safety-and-quality
July 01, 2017 - Commentary
Physician autonomy and informed decision making: finding the balance for patient safety and quality.
Citation Text:
Mathews SC, Pronovost P. Physician autonomy and informed decision making: finding the balance for patient safety and quality. JAMA. 2008;300(24):2913-5. doi:10…