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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47892/psn-pdf
    March 27, 2019 - Addressing medicine's bias against patients who are overweight. March 27, 2019 Rubin R. Addressing Medicine's Bias Against Patients Who Are Overweight. JAMA. 2019;321(10):925-927. doi:10.1001/jama.2019.0048. https://psnet.ahrq.gov/issue/addressing-medicines-bias-against-patients-who-are-overweight Patients with o…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73429/psn-pdf
    June 23, 2021 - Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. June 23, 2021 Farnborough, UK: Healthcare Safety Investigation Branch; June 2021. https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings Wrong site/wrong patent surgery is a persisten…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45904/psn-pdf
    October 24, 2017 - Addressing physician burnout: the way forward. October 24, 2017 Shanafelt TD, Dyrbye LN, West CP. Addressing Physician Burnout: The Way Forward. JAMA. 2017;317(9):901-902. doi:10.1001/jama.2017.0076. https://psnet.ahrq.gov/issue/addressing-physician-burnout-way-forward Burnout can diminish both patient safety and …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36511/psn-pdf
    January 07, 2011 - Facing ambiguous threats. January 7, 2011 Roberto MA, Bohmer RMJ, Edmondson A. Facing ambiguous threats. Harv Bus Rev. 2006;84(11):106-13, 157. https://psnet.ahrq.gov/issue/facing-ambiguous-threats This study describes how organizations respond to signs that may or may not portend future catastrophes. The authors…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43390/psn-pdf
    July 30, 2014 - Hazards tied to medical records rush. July 30, 2014 Rowland C. https://psnet.ahrq.gov/issue/hazards-tied-medical-records-rush Government incentives have led to rapid development and adoption of electronic health records (EHRs). This newspaper article examines some of the unintended consequences of implementing ele…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840163/psn-pdf
    November 16, 2022 - Deep Dive: Racial and Ethnic Disparities in Health and Healthcare. November 16, 2022 Plymouth Meeting, PA: ECRI and the Institute for Safe Medication Practices; 2022. https://psnet.ahrq.gov/issue/deep-dive-racial-and-ethnic-disparities-health-and-healthcare Racist behavior directed at either patients or clinicians…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44431/psn-pdf
    October 21, 2015 - Use of a human factors classification framework to identify causal factors for medication and medical device- related adverse clinical incidents. October 21, 2015 Mitchell RJ, Williamson A, Molesworth B. Use of a human factors classification framework to identify causal factors for medication and medical device-re…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46697/psn-pdf
    January 10, 2018 - Primary care providers' perspectives on errors of omission. January 10, 2018 Poghosyan L, Norful AA, Fleck E, et al. Primary Care Providers' Perspectives on Errors of Omission. J Am Board Fam Med. 2017;30(6):733-742. doi:10.3122/jabfm.2017.06.170161. https://psnet.ahrq.gov/issue/primary-care-providers-perspectives…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854992/psn-pdf
    November 01, 2023 - Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet? November 1, 2023 Roy JM, Rumalla K, Skandalakis GP, et al. Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet? A systematic review. Neurosurg Rev. 2023;46(1):227. doi:10.1007/s1014…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60797/psn-pdf
    August 12, 2020 - Nonoperating room anaesthesia: safety, monitoring, cognitive aids and severe acute respiratory syndrome coronavirus 2. August 12, 2020 Borshoff DC, Sadleir P. Nonoperating room anaesthesia: safety, monitoring, cognitive aids and severe acute respiratory syndrome coronavirus 2. Curr Opin Anaesthesiol. 2020;33(4):55…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48028/psn-pdf
    August 28, 2019 - Error Reduction and Prevention in Surgical Pathology, Second Edition. August 28, 2019 Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636. https://psnet.ahrq.gov/issue/error-reduction-and-prevention-surgical-pathology-2nd-edition Surgical specimen and laboratory process proble…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44989/psn-pdf
    July 01, 2016 - Can medical record reviewers reliably identify errors and adverse events in the ED? July 1, 2016 Klasco RS, Wolfe RE, Lee T, et al. Can medical record reviewers reliably identify errors and adverse events in the ED? Am J Emerg Med. 2016;34(6):1043-8. doi:10.1016/j.ajem.2016.03.001. https://psnet.ahrq.gov/issue/can…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37769/psn-pdf
    March 10, 2011 - Turning off frequently overridden drug alerts: limited opportunities for doing it safely. March 10, 2011 van der Sijs H, Aarts J, van Gelder T, et al. Turning off frequently overridden drug alerts: limited opportunities for doing it safely. J Am Med Inform Assoc. 2008;15(4):439-48. doi:10.1197/jamia.M2311. https:/…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46287/psn-pdf
    April 12, 2019 - Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned. April 12, 2019 Neily J, Silla ES, Sum-Ping S (J) T, et al. Anesthesia Adverse Events Voluntarily Reported in the Veterans Health Administration and Lessons Learned. Anesth Analg. 2017;126(2):471-477. doi:10.12…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47623/psn-pdf
    February 06, 2019 - Diagnostic heuristics in dermatology—part 1 and part 2. February 6, 2019 Lowenstein EJ, Sidlow R. Cognitive and visual diagnostic errors in dermatology: part 1 and part 2. J Dermatol. 2018;179(6):1263-1276. doi:10.1111/bjd.16932. https://psnet.ahrq.gov/issue/diagnostic-heuristics-dermatology-part-1-and-part-2 Cogn…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867144/psn-pdf
    November 13, 2024 - Life of the Mother. How Abortion Bans Lead to Preventable Deaths. November 13, 2024 Jaramillo C, Surana K, Presser L, et al. Life of the Mother. How Abortion Bans Lead to Preventable Deaths. ProPublica. 2024:September - November 2024. https://psnet.ahrq.gov/issue/life-mother-how-abortion-bans-lead-preventable-deat…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44285/psn-pdf
    November 06, 2015 - Hospital board oversight of quality and safety: a stakeholder analysis exploring the role of trust and intelligence. November 6, 2015 Millar R, Freeman T, Mannion R. Hospital board oversight of quality and safety: a stakeholder analysis exploring the role of trust and intelligence. BMC Health Serv Res. 2015;15:196…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44674/psn-pdf
    December 18, 2017 - Achieving Safe Health Care: Delivery of Safe Patient Care at Baylor Scott & White Health. December 18, 2017 Compton J. Boca Raton, FL: CRC Press; 2016. ISBN: 9781498732390. https://psnet.ahrq.gov/issue/achieving-safe-health-care-delivery-safe-patient-care-baylor-scott-white-health Since the publication of the Inst…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35237/psn-pdf
    November 29, 2009 - Improving nurse-to-patient staffing ratios as a cost- effective safety intervention. November 29, 2009 Rothberg MB, Abraham I, Lindenauer PK, et al. Improving nurse-to-patient staffing ratios as a cost-effective safety intervention. Med Care. 2005;43(8):785-91. https://psnet.ahrq.gov/issue/improving-nurse-patient-…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47852/psn-pdf
    May 08, 2019 - Impact of time pressure on dentists' diagnostic performance. May 8, 2019 Plessas A, Nasser M, Hanoch Y, et al. Impact of time pressure on dentists' diagnostic performance. J Dent. 2019;82:38-44. doi:10.1016/j.jdent.2019.01.011. https://psnet.ahrq.gov/issue/impact-time-pressure-dentists-diagnostic-performance This…

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