-
psnet.ahrq.gov/node/854259/psn-pdf
January 01, 2024 - The power of written word: reflection reduces errors of
omission.
October 4, 2023
Rao A, Heidemann LA, Hartley S, et al. The power of written word: reflection reduces errors of omission.
Clin Teach. 2024;21(1):e13630. doi:10.1111/tct.13630.
https://psnet.ahrq.gov/issue/power-written-word-reflection-reduces-errors-…
-
psnet.ahrq.gov/node/38046/psn-pdf
September 10, 2008 - Clinical and pathological disagreement upon the cause of
death in a teaching hospital: analysis of 100 autopsy
cases in a prospective study.
September 10, 2008
Pinto Carvalho FL, Cordeiro JA, Cury PM. Clinical and pathological disagreement upon the cause of death
in a teaching hospital: Analysis of 100 autopsy cas…
-
psnet.ahrq.gov/node/44520/psn-pdf
September 30, 2015 - Patient safety in dermatologic surgery: parts 1 and 2.
September 30, 2015
Lolis M, Dunbar SW, Goldberg DJ, et al. J Am Acad Dermatol. 2015;73(1):1-26.
https://psnet.ahrq.gov/issue/patient-safety-dermatologic-surgery-part-1-patient-safety-procedural-
dermatology-part-2
This two-part review series explores patient s…
-
psnet.ahrq.gov/node/46050/psn-pdf
August 03, 2017 - Video analysis of factors associated with response time
to physiologic monitor alarms in a children's hospital.
August 3, 2017
Bonafide CP, Localio R, Holmes JH, et al. Video Analysis of Factors Associated With Response Time to
Physiologic Monitor Alarms in a Children's Hospital. JAMA Pediatr. 2017;171(6):524-531.
…
-
psnet.ahrq.gov/node/841790/psn-pdf
September 01, 2021 - Diagnostic errors, health disparities, and artificial
intelligence: a combination for health or harm.
September 1, 2021
Ibrahim SA, Pronovost PJ. Diagnostic errors, health disparities, and artificial intelligence: a combination for
health or harm. JAMA Health Forum. 2021;2(9):e212430. doi:10.1001/jamahealthforum.20…
-
psnet.ahrq.gov/node/41801/psn-pdf
October 31, 2012 - First year with WHO Surgical Safety Checklist in 7148
otorhinolaryngological operations: use and user
attitudes.
October 31, 2012
Helmiö P, Takala A, Aaltonen L-M, et al. First year with WHO Surgical Safety Checklist in 7148
otorhinolaryngological operations: use and user attitudes. Clin Otolaryngol. 2012;37(4):30…
-
psnet.ahrq.gov/node/45588/psn-pdf
January 23, 2017 - Computer-assisted process modeling to enhance
intraoperative safety in cardiac surgery.
January 23, 2017
Tarola CL, Quin JA, Haime ME, et al. Computer-Assisted Process Modeling to Enhance Intraoperative
Safety in Cardiac Surgery. JAMA Surg. 2016;151(12):1183-1186. doi:10.1001/jamasurg.2016.2839.
https://psnet.ahrq…
-
psnet.ahrq.gov/node/866171/psn-pdf
June 19, 2024 - Keeping Children and Young People with Mental Health
Needs Safe: the Design of the Paediatric Ward.
June 19, 2024
Dorset, UK: Health Services Safety Investigations Body; May 2024
https://psnet.ahrq.gov/issue/keeping-children-and-young-people-mental-health-needs-safe-design-
paediatric-ward
Acute mental health car…
-
psnet.ahrq.gov/node/44149/psn-pdf
June 03, 2015 - Patient safety in home hemodialysis: quality assurance
and serious adverse events in the home setting.
June 3, 2015
Pauly RP, Eastwood DO, Marshall MR. Patient safety in home hemodialysis: quality assurance and serious
adverse events in the home setting. Hemodial Int. 2015;19 Suppl 1:S59-70. doi:10.1111/hdi.12248.
…
-
psnet.ahrq.gov/node/866195/psn-pdf
June 26, 2024 - The exaggerated benefits of failure.
June 26, 2024
Eskreis-Winkler L, Woolley K, Erensoy E, et al. The exaggerated benefits of failure. J Exp Psychol Gen.
2024;153(7):1920-1937. doi:10.1037/xge0001610.
https://psnet.ahrq.gov/issue/exaggerated-benefits-failure
Failure can be considered a learning opportunity under …
-
psnet.ahrq.gov/node/43616/psn-pdf
October 29, 2014 - Preventing Healthcare-Associated Infections: Results and
Lessons Learned from AHRQ's HAI Program.
October 29, 2014
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Infect Control Hosp Epidemiol. 2014;35(suppl 3):S1-
S141.
https://psnet.ahrq.gov/issue/preventing-healthcare-associated-infections-results-and-lesson…
-
psnet.ahrq.gov/node/861294/psn-pdf
January 24, 2024 - Shining a glaring light on surgery: technology that
records every move aims to improve safety.
January 24, 2024
Freyer FJ. Boston Globe. January 13, 2024.
https://psnet.ahrq.gov/issue/shining-glaring-light-surgery-technology-records-every-move-aims-improve-
safety
The surgical black box uses cameras and microphon…
-
psnet.ahrq.gov/node/39922/psn-pdf
October 13, 2010 - What’s past is prologue: organizational learning from a
serious patient injury.
October 13, 2010
Tamuz M, Franchois KE, Thomas EJ. What’s past is prologue: Organizational learning from a serious
patient injury. Saf Sci. 2010;49(1). doi:10.1016/j.ssci.2010.06.005.
https://psnet.ahrq.gov/issue/whats-past-prologue-or…
-
psnet.ahrq.gov/node/46670/psn-pdf
December 18, 2017 - A narrative review of the safety concerns of deprescribing
in older adults and strategies to mitigate potential harms.
December 18, 2017
Reeve E, Moriarty F, Nahas R, et al. A narrative review of the safety concerns of deprescribing in older
adults and strategies to mitigate potential harms. Expert Opin Drug Saf. 2…
-
psnet.ahrq.gov/node/74081/psn-pdf
November 17, 2021 - The influence of the availability heuristic on physicians in
the emergency department.
November 17, 2021
Ly DP. The influence of the availability heuristic on physicians in the emergency department. Ann Emerg
Med. 2021;78(5):650-657. doi:10.1016/j.annemergmed.2021.06.012.
https://psnet.ahrq.gov/issue/influence-ava…
-
psnet.ahrq.gov/node/46717/psn-pdf
April 16, 2018 - Reduction in opioid prescribing through evidence-based
prescribing guidelines.
April 16, 2018
Howard R, Waljee JF, Brummett CM, et al. Reduction in Opioid Prescribing Through Evidence-Based
Prescribing Guidelines. JAMA Surg. 2018;153(3):285-287. doi:10.1001/jamasurg.2017.4436.
https://psnet.ahrq.gov/issue/reductio…
-
psnet.ahrq.gov/node/45941/psn-pdf
March 08, 2017 - Medication errors associated with transition from insulin
pens to insulin vials.
March 8, 2017
Trimble AN, Bishop B, Rampe N. Medication errors associated with transition from insulin pens to insulin
vials. Am J Health Syst Pharm. 2017;74(2):70-75. doi:10.2146/ajhp150726.
https://psnet.ahrq.gov/issue/medication-er…
-
psnet.ahrq.gov/node/35417/psn-pdf
February 15, 2010 - Errors in laboratory medicine: practical lessons to
improve patient safety.
February 15, 2010
Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab
Med. 2005;129(10):1252-1261.
https://psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patie…
-
psnet.ahrq.gov/node/46676/psn-pdf
December 13, 2017 - Diagnostic errors by medical students: results of a
prospective qualitative study.
December 13, 2017
Braun LT, Zwaan L, Kiesewetter J, et al. Diagnostic errors by medical students: results of a prospective
qualitative study. BMC Med Educ. 2017;17(1):191. doi:10.1186/s12909-017-1044-7.
https://psnet.ahrq.gov/issue/…
-
psnet.ahrq.gov/node/38534/psn-pdf
January 31, 2013 - Health care information technology vendors' "hold
harmless" clause: implications for patients and clinicians.
January 31, 2013
Koppel R, Kreda D. Health care information technology vendors' "hold harmless" clause: implications for
patients and clinicians. JAMA. 2009;301(12):1276-8. doi:10.1001/jama.2009.398.
https…