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psnet.ahrq.gov/node/837982/psn-pdf
August 31, 2022 - Patient Safety Incident Response Framework.
August 31, 2022
London, England: NHS England; August 2022.
https://psnet.ahrq.gov/issue/patient-safety-incident-response-framework
Effective response to medical error requires a comprehensive systemic and process-focused incident
examination approach to ensure organizati…
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psnet.ahrq.gov/node/34637/psn-pdf
March 02, 2011 - Risk management: extreme honesty may be the best
policy.
March 2, 2011
Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med.
1999;131(12):963-967.
https://psnet.ahrq.gov/issue/risk-management-extreme-honesty-may-be-best-policy
This article reviews a humanistic risk management…
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psnet.ahrq.gov/node/73225/psn-pdf
May 05, 2021 - Black or 'other'? Doctors may be relying on race to make
decisions about your health.
May 5, 2021
Smith J, Spodak C. CNN. April 25, 2021.
https://psnet.ahrq.gov/issue/black-or-other-doctors-may-be-relying-race-make-decisions-about-your-health
Race-adjusted decision making tools perpetuate the potential for diagnos…
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psnet.ahrq.gov/node/42405/psn-pdf
July 10, 2013 - The role of patient involvement in the diagnostic process
in internal medicine: a cognitive approach.
July 10, 2013
Lucchiari C, Pravettoni G. The role of patient involvement in the diagnostic process in internal medicine: a
cognitive approach. Eur J Intern Med. 2013;24(5):411-5. doi:10.1016/j.ejim.2013.01.022.
ht…
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psnet.ahrq.gov/node/61124/psn-pdf
November 11, 2020 - Using Twitter to assess patient takes on patient
experience.
November 11, 2020
Heath S. Patient Engagement HIT. October 29, 2020.
https://psnet.ahrq.gov/issue/using-twitter-assess-patient-takes-patient-experience
Twitter is evolving as a useful data source for patient safety. This news story discusses an examinati…
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psnet.ahrq.gov/node/73896/psn-pdf
September 29, 2021 - Policies to promote shared responsibility for safer
electronic health records.
September 29, 2021
Sittig DF, Singh H. Policies to promote shared responsibility for safer electronic health records. JAMA.
2021;326(15):1477-1478. doi:10.1001/jama.2021.13945.
https://psnet.ahrq.gov/issue/policies-promote-shared-respon…
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psnet.ahrq.gov/node/44358/psn-pdf
September 24, 2016 - Interruptions and medication administration in critical
care.
September 24, 2016
Bower R, Jackson C, Manning JC. Interruptions and medication administration in critical care. Nurs Crit
Care. 2015;20(4):183-95. doi:10.1111/nicc.12185.
https://psnet.ahrq.gov/issue/interruptions-and-medication-administration-critical…
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psnet.ahrq.gov/node/866445/psn-pdf
August 07, 2024 - Diagnosis in the Era of Digital Health and Artificial
Intelligence: A Workshop.
August 7, 2024
Diagnosis in the Era of Digital Health and Artificial Intelligence: A Workshop.
https://psnet.ahrq.gov/issue/diagnosis-era-digital-health-and-artificial-intelligence-workshop
Digital health is emerging as a primary techn…
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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…
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psnet.ahrq.gov/node/43887/psn-pdf
April 08, 2018 - Types of diagnostic errors in neurological emergencies in
the emergency department.
April 8, 2018
Dubosh NM, Edlow JA, Lefton M, et al. Types of diagnostic errors in neurological emergencies in the
emergency department. Diagnosis (Berl). 2015;2(1):21-28. doi:10.1515/dx-2014-0040.
https://psnet.ahrq.gov/issue/types…
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psnet.ahrq.gov/node/854264/psn-pdf
October 04, 2023 - Patient death tied to lack of proper escalation process for
barcode scanning failures.
October 4, 2023
ISMP Medication Safety Alert! Acute Care edition. 2023;28(19):1-3.
https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures
Lack of experience with distinct process…
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psnet.ahrq.gov/node/47779/psn-pdf
June 12, 2019 - Medication accuracy in electronic health records for
microbial keratitis.
June 12, 2019
Ashfaq HA, Lester CA, Ballouz D, et al. Medication Accuracy in Electronic Health Records for Microbial
Keratitis. JAMA Ophthalmal. 2019;137(8):929-931. doi:10.1001/jamaophthalmol.2019.1444.
https://psnet.ahrq.gov/issue/medicati…
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psnet.ahrq.gov/node/837346/psn-pdf
June 08, 2022 - Decontamination of Surgical Instruments.
June 8, 2022
Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022.
https://psnet.ahrq.gov/issue/decontamination-surgical-instruments
Surgical equipment sterilization can be hampered by equipment design, production pressures, process
complexity and policy mi…
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psnet.ahrq.gov/node/865597/psn-pdf
April 17, 2024 - Discharge from Mental Health Care: Making it Safe and
Patient-centred.
April 17, 2024
Manchester, UK: Parliamentary and Health Service Ombudsman; March 2024.
https://psnet.ahrq.gov/issue/discharge-mental-health-care-making-it-safe-and-patient-centred
The provision of safe mental health care is receiving increased …
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psnet.ahrq.gov/node/43084/psn-pdf
May 19, 2014 - How can the criminal law support the provision of quality
in healthcare?
May 19, 2014
Yeung K, Horder J. How can the criminal law support the provision of quality in healthcare? BMJ Qual Saf.
2014;23(6):519-24. doi:10.1136/bmjqs-2013-002688.
https://psnet.ahrq.gov/issue/how-can-criminal-law-support-provision-quali…
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psnet.ahrq.gov/node/38952/psn-pdf
September 16, 2009 - Has the pendulum swung too far?; The impact of missed
abdominal injuries in the era of nonoperative
management.
September 16, 2009
Fairfax LM, Christmas B, Deaugustinis M, et al. Has the pendulum swung too far? The impact of missed
abdominal injuries in the era of nonoperative management. Am Surg. 2009;75(7):558-6…
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psnet.ahrq.gov/node/37575/psn-pdf
September 08, 2010 - Systematic review: the evidence that publishing patient
care performance data improves quality of care.
September 8, 2010
Fung CH, Lim Y-W, Mattke S, et al. Systematic review: the evidence that publishing patient care
performance data improves quality of care. Ann Intern Med. 2008;148(2):111-23.
https://psnet.ahrq…
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psnet.ahrq.gov/node/45039/psn-pdf
September 27, 2016 - Deaths following prehospital safety incidents: an analysis
of a national database.
September 27, 2016
Yardley I, Donaldson LJ. Deaths following prehospital safety incidents: an analysis of a national database.
Emerg Med J. 2016;33(10):716-721. doi:10.1136/emermed-2015-204724.
https://psnet.ahrq.gov/issue/deaths-fo…
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psnet.ahrq.gov/node/866935/psn-pdf
October 09, 2024 - The Economics of Diagnostic Safety.
October 9, 2024
de Bienassis K, Slawomirski L, Kelly D, et al. The Economics Of Diagnostic Safety. Paris, France: OECD
Publishing; 2023.
https://psnet.ahrq.gov/issue/economics-diagnostic-safety
Ineffective diagnostic processes are common, wasteful, and harmful. This analysis exa…
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psnet.ahrq.gov/issue/deny-dismiss-dehumanise-what-happened-when-i-went-hospital
September 09, 2015 - March 18, 2020
Examining causes and prevention strategies of adverse events in deceased