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3541. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35069/psn-pdf
      June 22, 2009 - Towards an organization with a memory: exploring the organizational generation of adverse events in health care. June 22, 2009 Smith D, Toft B. Towards an organization with a memory: exploring the organizational generation of adverse events in health care. Health Serv Manage Res. 2005;18(2). doi:10.1258/0951484053…

3542. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43184/psn-pdf
      May 14, 2014 - Often overlooked problems with handoffs: from the intensive care unit to the operating room. May 14, 2014 Evans AS, Yee M-S, Hogue CW. Often overlooked problems with handoffs: from the intensive care unit to the operating room. Anesth Analg. 2014;118(3):687-9. doi:10.1213/ANE.0000000000000075. https://psnet.ahrq.g…

3543. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74015/psn-pdf
      October 27, 2021 - Safer Services: A Toolkit for Specialist Mental Health Services and Primary Care. October 27, 2021 National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of Manchester; May 31, 2021 https://psnet.ahrq.gov/issue/safer-services-toolkit-specialist-mental-health-services-and…

3544. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34797/psn-pdf
      October 06, 2015 - Adapting to new technologies in the operating room. October 6, 2015 Cook RI, Woods DD. Adapting to New Technology in the Operating Room. Hum Factors. 2006;38(4):593- 613. doi:10.1518/001872096778827224. https://psnet.ahrq.gov/issue/adapting-new-technologies-operating-room New technology continues to offer great ad…

3545. 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…

3546. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43478/psn-pdf
      August 27, 2014 - Is it time to move beyond errors in clinical reasoning and discuss accuracy? August 27, 2014 Wood TJ. Is it time to move beyond errors in clinical reasoning and discuss accuracy? Adv Health Sci Educ Theory Pract. 2014;19(3):403-407. doi:10.1007/s10459-014-9498-4. https://psnet.ahrq.gov/issue/it-time-move-beyond-er…

3547. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46206/psn-pdf
      August 02, 2017 - Patient safety in dentistry: development of a candidate 'never event' list for primary care. August 2, 2017 Black I, Bowie P. Patient safety in dentistry: development of a candidate 'never event' list for primary care. Br Dent J. 2017;222(10):782-788. doi:10.1038/sj.bdj.2017.456. https://psnet.ahrq.gov/issue/patie…

3548. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60625/psn-pdf
      June 24, 2020 - Medical bias: from pain pills to COVID-19, racial discrimination in health care festers. June 24, 2020 O'Donnell J, Alltucker K. Medical bias: from pain pills to COVID-19, racial discrimination in health care festers. USA Today. 2020;Jun 14. https://psnet.ahrq.gov/issue/medical-bias-pain-pills-covid-19-racial-disc…

3549. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44463/psn-pdf
      September 16, 2015 - The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews. September 16, 2015 Kringos DS, Suñol R, Wagner C, et al. The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews. BMC Health Ser…

3550. 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…

3551. 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…

3552. 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…

3553. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48159/psn-pdf
      July 31, 2019 - Fatigue in radiology: a fertile area for future research. July 31, 2019 Taylor-Phillips S, Stinton C. Fatigue in radiology: a fertile area for future research. Br J Radiol. 2019;92(1099):20190043. doi:10.1259/bjr.20190043. https://psnet.ahrq.gov/issue/fatigue-radiology-fertile-area-future-research Physician fatigu…

3554. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46621/psn-pdf
      November 22, 2017 - Patient involvement for improved patient safety: a qualitative study of nurses' perceptions and experiences. November 22, 2017 Skagerström J, Ericsson C, Nilsen P, et al. Patient involvement for improved patient safety: A qualitative study of nurses' perceptions and experiences. Nurs Open. 2017;4(4):230-239. doi:10…

3555. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50925/psn-pdf
      February 19, 2020 - Report of the Independent Inquiry into the Issues Raised by Paterson. February 19, 2020 James G. House Commons Report 31. Department of Health and Social Care. London, England: Crown Copyright; 2020. ISBN 9781528617284. https://psnet.ahrq.gov/issue/report-independent-inquiry-issues-raised-paterson Shari…

3556. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44890/psn-pdf
      July 11, 2017 - The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting. July 11, 2017 Her QL, Amato MG, Seger DL, et al. The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting. J Am Med Inform Assoc. 2016;23(5):924-33. doi:10.1093/jamia/ocv181. http…

3557. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60016/psn-pdf
      March 04, 2020 - The influence of bullying on nursing practice errors: a systematic review. March 4, 2020 Johnson AH, Benham?Hutchins M. The Influence of Bullying on Nursing Practice Errors: A Systematic Review. AORN J. 2020;111(2). doi:10.1002/aorn.12923. https://psnet.ahrq.gov/issue/influence-bullying-nursing-practice-errors-sys…

3558. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46457/psn-pdf
      December 20, 2017 - Simulation and the diagnostic process: a pilot study of trauma and rapid response teams. December 20, 2017 Juriga LL, Murray DJ, Boulet JR, et al. Simulation and the diagnostic process: a pilot study of trauma and rapid response teams. Diagnosis (Berl). 2017;4(4):241-249. doi:10.1515/dx-2017-0010. https://psnet.ah…

3559. 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…

3560. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47023/psn-pdf
      January 16, 2019 - Usability testing of a mobile app to report medication errors anonymously: mixed-methods approach. January 16, 2019 George D, Hassali MA, Hss A-S. Usability Testing of a Mobile App to Report Medication Errors Anonymously: Mixed-Methods Approach. JMIR Hum Factors. 2018;5(4):e12232. doi:10.2196/12232. https://psnet.…