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Life after death: the aftermath of perioperative catastrophes. | PSNet

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March 29, 2012 - Review Life after death: the aftermath of perioperative catastrophes. Citation Text: Gazoni FM, Durieux ME, Wells L. Life after death: the aftermath of perioperative catastrophes. Anesth Analg. 2008;107(2):591-600. doi:10.1213/ane.0b013e31817a9c77. Copy Citation Format: D…

Lessons from the war on cancer: the need for basic research on safety. | PSNet

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July 14, 2010 - Commentary Lessons from the war on cancer: the need for basic research on safety. Citation Text: Lessons from the war on cancer: the need for basic research on safety. Cook RI. J Patient Saf. 2005.1(1):7-8 Copy Citation Save Save to your library Print Do…

Human factors and systems engineering approach to patient safety for radiotherapy. | PSNet

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August 07, 2013 - Commentary Human factors and systems engineering approach to patient safety for radiotherapy. Citation Text: Human factors and systems engineering approach to patient safety for radiotherapy. Rivera AJ, Karsh B-T. Int J Radiat Oncol Biol Phys. 2008;71:S174-S177. Copy Citation …

Normalization of deviance is contrary to the principles of high reliability. | PSNet

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June 09, 2021 - Commentary Normalization of deviance is contrary to the principles of high reliability. Citation Text: Wright I. Normalization of deviance Is contrary to the principles of high reliability. AORN J. 2023;117(4):231-238. doi:10.1002/aorn.13894. Copy Citation Format: DOI Googl…

Misinformation in the medical literature: what role do error and fraud play? | PSNet

psnet.ahrq.gov/issue/misinformation-medical-literature-what-role-do-error-and-fraud-play

November 02, 2011 - Commentary Misinformation in the medical literature: what role do error and fraud play? Citation Text: Steen G. Misinformation in the medical literature: what role do error and fraud play? J Med Ethics. 2011;37(8):498-503. doi:10.1136/jme.2010.041830. Copy Citation Format: …

Medication handling: towards a practical, human-centred approach. | PSNet

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September 23, 2020 - Commentary Medication handling: towards a practical, human-centred approach. Citation Text: Marshall SD, Chrimes N. Medication handling: towards a practical, human-centred approach. Anaesthesia. 2019;74(3):280-284. doi:10.1111/anae.14482. Copy Citation Format: DOI Google Sc…

Poor physician-patient communication and medical error. | PSNet

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August 23, 2023 - Commentary Poor physician-patient communication and medical error. Citation Text: Poor physician-patient communication and medical error. Lazris A, Roth AR, Haskell H, et al. Am Fam Physician. 2021;103(12):757-759. Copy Citation Save Save to yo…

Using AHRQ’s SOPS Hospital Survey and Workplace Safety Item Set: Experiences From a State Hospital Association. | PSNet

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March 22, 2024 - Meeting/Conference Proceedings Using AHRQ’s SOPS Hospital Survey and Workplace Safety Item Set: Experiences From a State Hospital Association. Citation Text: Using AHRQ’s SOPS Hospital Survey and Workplace Safety Item Set: Experiences From a State Hospital Association. Agency for Healthc…

Medical emergency team: a review of the literature. | PSNet

psnet.ahrq.gov/issue/medical-emergency-team-review-literature

March 02, 2011 - Review Medical emergency team: a review of the literature. Citation Text: Barbetti J, Lee G. Medical emergency team: a review of the literature. Nurs Crit Care. 2008;13(2):80-85. doi:10.1111/j.1478-5153.2007.00258.x. Copy Citation Format: DOI Google Scholar PubMed BibTeX …

Three quarters of preventable patient harm stems from situation awareness breakdowns: recognizing and addressing the core issue. | PSNet

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September 11, 2009 - Newspaper/Magazine Article Three quarters of preventable patient harm stems from situation awareness breakdowns: recognizing and addressing the core issue. Citation Text: Three quarters of preventable patient harm stems from situation awareness breakdowns: recognizing and addressing the …

Global Report on Infection Prevention and Control: Executive Summary. | PSNet

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March 09, 2022 - Book/Report Global Report on Infection Prevention and Control: Executive Summary. Citation Text: Global Report on Infection Prevention and Control: Executive Summary. Geneva, Switzerland; World Health Organization; May 5, 2022. Copy Citation Save Save to your li…

Changing our culture: adopting the military aviation safety system. | PSNet

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November 21, 2021 - Commentary Changing our culture: adopting the military aviation safety system. Citation Text: Kerber CW. Changing our culture: adopting the military aviation safety system. J Neurointerv Surg. 2014;6(5):332-41. doi:10.1136/neurintsurg-2013-011070. Copy Citation Format: DOI …

The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul. | PSNet

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September 28, 2022 - Book/Report The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul. Citation Text: The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul. de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Econo…

Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints. | PSNet

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October 12, 2022 - Book/Report Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints. Citation Text: Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints. Washington, DC: United States Government Accountability Office; N…

An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS Chaired by the Chief Medical Officer. | PSNet

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June 12, 2013 - Book/Report Classic An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS Chaired by the Chief Medical Officer. Citation Text: An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events …

The incidence of diagnostic error in medicine. | PSNet

psnet.ahrq.gov/issue/incidence-diagnostic-error-medicine

July 15, 2015 - Review The incidence of diagnostic error in medicine. Citation Text: Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf. 2013;22 Suppl 2:ii21-ii27. doi:10.1136/bmjqs-2012-001615. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML End…

Becoming a high-reliability organization through shared learning of safety events | PSNet

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February 12, 2020 - Newspaper/Magazine Article Becoming a high-reliability organization through shared learning of safety events Citation Text: Becoming a high-reliability organization through shared learning of safety events Klenklen J. Patient Saf Qual HCare. December 19, 2019. Copy Citation …

Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). | PSNet

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May 03, 2023 - Newspaper/Magazine Article Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). Citation Text: Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). ISMP M…

System Governance Towards Improved Patient Safety: Key Functions, Approaches and Pathways to Implementation. | PSNet

psnet.ahrq.gov/issue/system-governance-towards-improved-patient-safety-key-functions-approaches-and-pathways

October 07, 2020 - Book/Report System Governance Towards Improved Patient Safety: Key Functions, Approaches and Pathways to Implementation. Citation Text: System Governance Towards Improved Patient Safety: Key Functions, Approaches and Pathways to Implementation. Auraaen A, Saar K, Klazinga N for the Organ…

Advancing Maternal Health Equity and Reducing Maternal Mortality Workshop. | PSNet

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May 19, 2021 - Meeting/Conference Proceedings Advancing Maternal Health Equity and Reducing Maternal Mortality Workshop. Citation Text: Advancing Maternal Health Equity and Reducing Maternal Mortality Workshop. National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021. Copy Citatio…

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