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2301. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47967/psn-pdf
      May 01, 2019 - The Harvard Medical Practice Study trigger system performance in deceased patients. May 1, 2019 Klein DO, Rennenberg RJMW, Koopmans RP, et al. The Harvard medical practice study trigger system performance in deceased patients. BMC Health Serv Res. 2019;19(1):16. doi:10.1186/s12913-018-3839-6. https://psnet.ahrq.go…

2302. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60648/psn-pdf
      July 01, 2020 - Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives. July 1, 2020 Osterholm MT, Olshaker M. Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives. Foreign Affairs. 2020;99:4. https://psnet.ahrq.gov/issue/chronicle-pan…

2303. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74065/psn-pdf
      November 10, 2021 - AHRQ announces interest in research on digital healthcare safety. November 10, 2021 Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 28, 2021 Publication No. NOT-HS-22-004. https://psnet.ahrq.gov/issue/ahrq-announces-interest-research-digital-healthcare-safety Digital in…

2304. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34998/psn-pdf
      June 22, 2009 - Cause and effect analysis of closed claims in obstetrics and gynecology. June 22, 2009 White AA, Pichert JW, Bledsoe SH, et al. Cause and effect analysis of closed claims in obstetrics and gynecology. Obstet Gynecol. 2005;105(5 Pt 1):1031-1038. https://psnet.ahrq.gov/issue/cause-and-effect-analysis-closed-claims-o…

2305. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837041/psn-pdf
      May 04, 2022 - APSF endorsed statement on revising recommendations for patient monitoring during anesthesia. May 4, 2022 The APSF Committee on Technology. APSF Newsletter. 2022;37(1):7–8. https://psnet.ahrq.gov/issue/apsf-endorsed-statement-revising-recommendations-patient-monitoring-during- anesthesia Variation across sta…

2306. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44833/psn-pdf
      April 22, 2016 - The contribution of sociotechnical factors to health information technology–related sentinel events. April 22, 2016 Castro GM, Buczkowski L, Hafner JM. The Contribution of Sociotechnical Factors to Health Information Technology-Related Sentinel Events. Jt Comm J Qual Patient Saf. 2016;42(2):70-76. https://psnet.ah…

2307. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867020/psn-pdf
      October 23, 2024 - What can we learn from coroners’ reports on preventable deaths? October 23, 2024 Jeraj S. What can we learn from coroners’ reports on preventable deaths? BMJ. 2024;386:q1943. https://psnet.ahrq.gov/issue/what-can-we-learn-coroners-reports-preventable-deaths Analysis of system failure is only the beginning of the i…

2308. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47350/psn-pdf
      November 29, 2018 - Do crowdsourced hospital ratings coincide with Hospital Compare measures of clinical and nonclinical quality? November 29, 2018 Perez V, Freedman S. Do Crowdsourced Hospital Ratings Coincide with Hospital Compare Measures of Clinical and Nonclinical Quality? Health Serv Res. 2018;53(6):4491-4506. doi:10.1111/1475-6…

2309. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61051/psn-pdf
      October 21, 2020 - Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). October 21, 2020 ISMP Medication Safety Alert! Acute Care Edition. October 8, 2020;25(20):1-4 https://psnet.ahrq.gov/issue/safety-investigations-across-pond-deep-learning-englands-healthcare-safe…

2310. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/855100/psn-pdf
      November 08, 2023 - Prescription for disaster: America's broken pharmacy system in revolt over burnout and errors. November 8, 2023 Le Coz E. USA Today. October 26, 2023. https://psnet.ahrq.gov/issue/prescription-disaster-americas-broken-pharmacy-system-revolt-over-burnout- and-errors Chain pharmacies provide prescriptions in an env…

2311. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/844748/psn-pdf
      February 15, 2023 - 'They were his best shot. And they failed to help’: why did EMS workers neglect Tyre Nichols? February 15, 2023 Renault M. STAT. February 6, 2023. https://psnet.ahrq.gov/issue/they-were-his-best-shot-and-they-failed-help-why-did-ems-workers-neglect- tyre-nichols Emergent care situations are vulnerable to a range …

2312. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73522/psn-pdf
      July 21, 2021 - Federal speech rulings may embolden health care workers to call out safety issues. July 21, 2021 Meyer H. Kaiser Health News. July 9, 2021. https://psnet.ahrq.gov/issue/federal-speech-rulings-may-embolden-health-care-workers-call-out-safety- issues Whistleblower protections are a key component to raising awarenes…

2313. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48102/psn-pdf
      August 07, 2019 - The unmeasured quality metric: burn out and the second victim syndrome in healthcare. August 7, 2019 Heiss K, Clifton M. The unmeasured quality metric: Burn out and the second victim syndrome in healthcare. Semin Pediatr Surg. 2019;28(3):189-194. doi:10.1053/j.sempedsurg.2019.04.011. https://psnet.ahrq.gov/issue/u…

2314. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73328/psn-pdf
      May 26, 2021 - Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia. May 26, 2021 Washington DC:  Department of Veterans Affairs. Office of Inspector General; May 11, 2021. Report No. 20-03593-140. https://psnet.ahrq.gov/issue/care-and-oversigh…

2315. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43906/psn-pdf
      May 13, 2015 - Nursing handovers as resilient points of care: linking handover strategies to treatment errors in the patient care in the following shift. May 13, 2015 Drach-Zahavy A, Hadid N. Nursing handovers as resilient points of care: linking handover strategies to treatment errors in the patient care in the following shift.…

2316. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48036/psn-pdf
      July 10, 2019 - Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior. July 10, 2019 Stratman JL, Youssef-Morgan CM. Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior. Safety Sci. 2019;116:13-25. doi:10.1016/j.ssci.2019.02.031. htt…

2317. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47274/psn-pdf
      November 21, 2018 - Developing a hospital-wide quality and safety dashboard: a qualitative research study. November 21, 2018 Weggelaar-Jansen AMJWM, Broekharst DSE, de Bruijne M. Developing a hospital-wide quality and safety dashboard: a qualitative research study. BMJ Qual Saf. 2018;27(12):1000-1007. doi:10.1136/bmjqs-2018- 007784. …

2318. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44371/psn-pdf
      September 09, 2015 - Acute stroke chameleons in a university hospital: risk factors, circumstances, and outcomes. September 9, 2015 Richoz B, Hugli O, Dami F, et al. Acute stroke chameleons in a university hospital: Risk factors, circumstances, and outcomes. Neurology. 2015;85(6):505-11. doi:10.1212/WNL.0000000000001830. https://psnet…

2319. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46503/psn-pdf
      January 31, 2018 - Clinical decision-making: heuristics and cognitive biases for the ophthalmologist. January 31, 2018 Hussain A, Oestreicher J. Clinical decision-making: heuristics and cognitive biases for the ophthalmologist. Surv Ophthalmol. 2018;63(1):119-124. doi:10.1016/j.survophthal.2017.08.007. https://psnet.ahrq.gov/issue/c…

2320. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40321/psn-pdf
      March 30, 2011 - Inaccuracies in assignment of clinical stage for localized prostate cancer. March 30, 2011 Reese AC, Sadetsky N, Carroll PR, et al. Inaccuracies in assignment of clinical stage for localized prostate cancer. Cancer. 2011;117(2):283-9. doi:10.1002/cncr.25596. https://psnet.ahrq.gov/issue/inaccuracies-assignment-cli…