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5061. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72686/psn-pdf
      January 27, 2021 - The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making. January 27, 2021 Croskerry P. New York, NY: Oxford University Press; 2020. ISBN: 9780190088743.  https://psnet.ahrq.gov/issue/cognitive-autopsy-root-cause-analysis-medical-decision-making Diagnostic error reduction methods are evolv…

5062. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41934/psn-pdf
      May 24, 2016 - Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration. May 24, 2016 Tucker AL. Cambridge, MA: Harvard Business School; November 19, 2012. (Revised September 2013). HBS Working Paper No. 13-044. https://psnet.ahrq.gov/issue/work-design-drive…

5063. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838639/psn-pdf
      October 19, 2022 - Calibrate Dx: A Resource to Improve Diagnostic Decisions. October 19, 2022 Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)- 0047-2-EF. https://psnet.ahrq.gov/issue/calibrate-dx-resource-improve-diagnostic-decisions Delayed, wrong, and missed diagnoses are commo…

5064. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48182/psn-pdf
      August 21, 2019 - Organizational learning in hospitals: a realist review. August 21, 2019 Lyman B, Jacobs JD, Hammond EL, et al. Organizational learning in hospitals: A realist review. J Adv Nurs. 2019;75(11):2352-2377. doi:10.1111/jan.14091. https://psnet.ahrq.gov/issue/organizational-learning-hospitals-realist-review Organization…

5065. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35375/psn-pdf
      January 02, 2017 - Integrating the intensive care unit safety reporting system with existing incident reporting systems. January 2, 2017 Thompson DA, Lubomski LH, Holzmueller CG, et al. Integrating the intensive care unit safety reporting system with existing incident reporting systems. Jt Comm J Qual Patient Saf. 2005;31(10):585-93.…

5066. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44332/psn-pdf
      July 29, 2015 - Health IT Safety Center Roadmap. July 29, 2015 RTI International. Washington, DC: Office of the National Coordinator for Health Information Technology; July 2015. https://psnet.ahrq.gov/issue/health-it-safety-center-roadmap The Institute of Medicine called for enhanced transparency in the reporting of health IT sa…

5067. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44475/psn-pdf
      October 03, 2017 - Scoring no goal—further adventures in transparency. October 3, 2017 Rosenbaum L. Scoring No Goal--Further Adventures in Transparency. N Engl J Med. 2015;373(15):1385- 8. doi:10.1056/NEJMp1510094. https://psnet.ahrq.gov/issue/scoring-no-goal-further-adventures-transparency This commentary explores challenges to mon…

5068. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45303/psn-pdf
      June 15, 2017 - The global burden of diagnostic errors in primary care. June 15, 2017 Singh H, Schiff G, Graber ML, et al. The global burden of diagnostic errors in primary care. BMJ Qual Saf. 2017;26(6):484-494. doi:10.1136/bmjqs-2016-005401. https://psnet.ahrq.gov/issue/global-burden-diagnostic-errors-primary-care The need to i…

5069. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47387/psn-pdf
      September 12, 2018 - Guideline implementation: team communication. September 12, 2018 Link T. Guideline Implementation: Team Communication: 1.8 www.aornjournal.org/content/cme. AORN J. 2018;108(2):165-177. doi:10.1002/aorn.12300. https://psnet.ahrq.gov/issue/guideline-implementation-team-communication Although team development has rec…

5070. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60153/psn-pdf
      March 25, 2020 - A protocol for the safe use of hazardous drugs in the OR. March 25, 2020 Hemingway MW, Meleis L, Oliver J, et al. A protocol for the safe use of hazardous drugs in the OR. AORN J. 2020;111(3). doi:10.1002/aorn.12960. https://psnet.ahrq.gov/issue/protocol-safe-use-hazardous-drugs-or Perioperative personnel often ca…

5071. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43062/psn-pdf
      September 04, 2016 - The relationship between patient safety culture and patient outcomes: a systematic review. September 4, 2016 DiCuccio MH. The Relationship Between Patient Safety Culture and Patient Outcomes: A Systematic Review. J Patient Saf. 2015;11(3):135-42. doi:10.1097/PTS.0000000000000058. https://psnet.ahrq.gov/issue/relat…

5072. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42984/psn-pdf
      February 26, 2014 - Delivering the truth: challenges and opportunities for error disclosure in obstetrics. February 26, 2014 Carranza L, Lyerly AD, Lipira L, et al. Delivering the Truth. Obstetrics & Gynecology. 2014;123(3). doi:10.1097/aog.0000000000000130. https://psnet.ahrq.gov/issue/delivering-truth-challenges-and-opportunities-e…

5073. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846167/psn-pdf
      March 15, 2023 - Diagnostic stewardship to prevent diagnostic error. March 15, 2023 Morgan DJ, Malani PN, Diekema DJ. Diagnostic stewardship to prevent diagnostic error. JAMA. 2023;329(15):1255-1256. doi:10.1001/jama.2023.1678. https://psnet.ahrq.gov/issue/diagnostic-stewardship-prevent-diagnostic-error The effective use of resour…

5074. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39572/psn-pdf
      January 03, 2017 - The tangible handoff: a team approach for advancing structured communication in labor and delivery. January 3, 2017 Block M, Ehrenworth JF, Cuce VM, et al. The tangible handoff: a team approach for advancing structured communication in labor and delivery. Jt Comm J Qual Patient Saf. 2010;36(6):282-287, 241. https:…

5075. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46043/psn-pdf
      April 05, 2017 - High-reliability and the I-PASS communication tool. April 5, 2017 Clements K. High-reliability and the I-PASS communication tool. Nursing Management (Springhouse). 2017;48(3). doi:10.1097/01.numa.0000512897.68425.e5. https://psnet.ahrq.gov/issue/high-reliability-and-i-pass-communication-tool High reliability has y…

5076. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47003/psn-pdf
      July 18, 2018 - Impact of an antiretroviral stewardship strategy on medication error rates. July 18, 2018 Shea KM, Hobbs AL, Shumake JD, et al. Impact of an antiretroviral stewardship strategy on medication error rates. Am J Health Syst Pharm. 2018;75(12):876-885. doi:10.2146/ajhp170420. https://psnet.ahrq.gov/issue/impact-antire…

5077. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44090/psn-pdf
      November 21, 2016 - Insensible losses: when the medical community forgets the family. November 21, 2016 Elias P. Insensible losses: when the medical community forgets the family. Health Aff (Millwood). 2015;34(4):707-710. doi:10.1377/hlthaff.2014.0536. https://psnet.ahrq.gov/issue/insensible-losses-when-medical-community-forgets-fami…

5078. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842777/psn-pdf
      January 18, 2023 - Patient safety performance: reversing recent declines through shared profession-wide system-level solutions. January 18, 2023 doi:full/10.1056/CAT.22.0318. https://psnet.ahrq.gov/issue/patient-safety-performance-reversing-recent-declines-through-shared- profession-wide-system The COVID-19 pandemic revealed fractu…

5079. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39374/psn-pdf
      March 17, 2010 - Bridging the gap: leveraging business intelligence tools in support of patient safety and financial effectiveness. March 17, 2010 Ferranti JM, Langman MK, Tanaka D, et al. Bridging the gap: leveraging business intelligence tools in support of patient safety and financial effectiveness. J Am Med Inform Assoc. 2010;1…

5080. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42976/psn-pdf
      May 29, 2014 - Quality and safety in pediatric hematology/oncology. May 29, 2014 Mueller BU. Quality and safety in pediatric hematology/oncology. Pediatr Blood Cancer. 2014;61(6):966-9. doi:10.1002/pbc.24946. https://psnet.ahrq.gov/issue/quality-and-safety-pediatric-hematologyoncology Children with cancer are particularly vulner…