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psnet.ahrq.gov/node/35487/psn-pdf
September 12, 2016 - Safety improvements urged for MRI facilities.
September 12, 2016
Mitka M. Safety improvements urged for MRI facilities. JAMA. 2005;294(17):2145-8.
https://psnet.ahrq.gov/issue/safety-improvements-urged-mri-facilities
This news story from JAMA summarizes a teleconference on magnetic resonance imaging safety
and sha…
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psnet.ahrq.gov/node/39347/psn-pdf
September 30, 2015 - MGH death spurs review of patient monitors.
September 30, 2015
Kowalczyk L. Boston Globe. February 21, 2010.
https://psnet.ahrq.gov/issue/mgh-death-spurs-review-patient-monitors
This news account discusses a patient death after a heart monitor alarm was inadvertently turned off.
Hospital and device safety experts …
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psnet.ahrq.gov/node/34974/psn-pdf
February 08, 2011 - A model patient: how simulators are changing the way
doctors are trained.
February 8, 2011
https://psnet.ahrq.gov/issue/model-patient-how-simulators-are-changing-way-doctors-are-trained
Through discussions with numerous experts and medical educators, this piece explores how simulation
training has developed over t…
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psnet.ahrq.gov/node/37230/psn-pdf
October 21, 2007 - Former pharmacist indicted for manslaughter after med
error.
October 21, 2007
Paul R. Drug Topics. September 17, 2007.
https://psnet.ahrq.gov/issue/former-pharmacist-indicted-manslaughter-after-med-error
This article reports on an error for which criminal charges were filed against the pharmacist and his license
…
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psnet.ahrq.gov/node/36978/psn-pdf
September 19, 2016 - TRUST: the 5 rights of the second victim.
September 19, 2016
Denham CR. TRUST. J Patient Saf. 2008;3(2). doi:10.1097/01.jps.0000236917.02321.fd.
https://psnet.ahrq.gov/issue/trust-5-rights-second-victim
The author discusses the psychological impact of medical error on clinicians and shares interviews with
several …
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psnet.ahrq.gov/node/37353/psn-pdf
March 28, 2012 - Medication Use: A Systems Approach to Reducing Errors,
Second Edition.
March 28, 2012
Porche? RA. Oakbrook Terrace, IL: Joint Commission Resources: 2008. ISBN 9781599400976.
https://psnet.ahrq.gov/issue/medication-use-systems-approach-reducing-errors-second-edition
Co-authored by a host of medication safety expert…
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psnet.ahrq.gov/node/36216/psn-pdf
August 03, 2012 - Hospital Medication Errors Commonplace.
August 3, 2012
Berwick D; Lassman S; Bates D. National Public Radio. July 28, 2006.
https://psnet.ahrq.gov/issue/hospital-medication-errors-commonplace
This segment features Donald Berwick, David Bates, and other experts discussing the Institute of Medicine
(IOM) report Prev…
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psnet.ahrq.gov/node/35033/psn-pdf
May 18, 2005 - Medical errors still claiming many lives.
May 18, 2005
Weise E. USA Today. May 18, 2005.
https://psnet.ahrq.gov/issue/medical-errors-still-claiming-many-lives
This article highlights a commentary published in JAMA by two leading experts in patient safety
which summarizes the progress made since publication of the …
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psnet.ahrq.gov/node/43267/psn-pdf
June 11, 2014 - The PROTECT Initiative: Advancing Children's Medication
Safety.
June 11, 2014
US Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/protect-initiative-advancing-childrens-medication-safety
This Web site offers resources related to a collaborative involving public health agencies, private
org…
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psnet.ahrq.gov/node/35488/psn-pdf
July 31, 2012 - American College of Radiology White Paper on MR
Safety: 2004 Update and Revisions.
July 31, 2012
doi:10.2214/ajr.182.5.182111.
https://psnet.ahrq.gov/issue/american-college-radiology-white-paper-mr-safety-2004-update-and-revisions
This white paper combines two reports from the ACR Blue Ribbon Panel on MR Safety. E…
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psnet.ahrq.gov/node/37976/psn-pdf
December 14, 2010 - Practicing Medicine in Difficult Times: Protecting
Physicians from Malpractice Litigation.
December 14, 2010
Thomas MO, Quinn CJ, Donohue GM. Sudbury, MA: Jones Bartlett; 2009. ISBN: 100763748560.
https://psnet.ahrq.gov/issue/practicing-medicine-difficult-times-protecting-physicians-malpractice-litigation
Written …
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psnet.ahrq.gov/node/37864/psn-pdf
August 06, 2016 - Improving Healthcare Team Communication: Building on
Lessons from Aviation and Aerospace.
August 6, 2016
Nemeth CP, ed. Burlington, VT: Ashgate Publishing; 2008. ISBN: 9780754670254.
https://psnet.ahrq.gov/issue/improving-healthcare-team-communication-building-lessons-aviation-and-
aerospace
This book provides an…
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psnet.ahrq.gov/node/38336/psn-pdf
January 14, 2009 - Proceedings of a summit on preventing patient harm and
death from IV medication errors.
January 14, 2009
Proceedings of a summit on preventing patient harm and death from i.v. medication errors.
doi:10.2146/ajhp080406.
https://psnet.ahrq.gov/issue/proceedings-summit-preventing-patient-harm-and-death-iv-medication-…
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psnet.ahrq.gov/node/41674/psn-pdf
September 12, 2012 - Medical errors harm huge number of patients. What will it
take to make America's hospitals safer?
September 12, 2012
Sternberg S.
https://psnet.ahrq.gov/issue/medical-errors-harm-huge-number-patients-what-will-it-take-make-americas-
hospitals-safer
This magazine article discusses insights from experts and patient…
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psnet.ahrq.gov/node/35538/psn-pdf
March 29, 2010 - Identifying medical errors: developing consensus on
classifications and consequences.
March 29, 2010
Hobgood C; Eaton J; Weiner BJ.
https://psnet.ahrq.gov/issue/identifying-medical-errors-developing-consensus-classifications-and-
consequences
The investigators surveyed a panel of experts to determine if they coul…
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psnet.ahrq.gov/issue/how-willing-are-patients-question-healthcare-staff-issues-related-quality-and-safety-their
July 31, 2008 - Study
How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study.
Citation Text:
Davis R, Koutantji M, Vincent C. How willing are patients to question healthcare staff on issues related to the quality and …
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psnet.ahrq.gov/issue/finding-and-fixing-mistakes-do-checklists-work-clinicians-different-levels-experience
February 06, 2014 - Study
Finding and fixing mistakes: do checklists work for clinicians with different levels of experience?
Citation Text:
Sibbald M, de Bruin A, van Merrienboer JJG. Finding and fixing mistakes: do checklists work for clinicians with different levels of experience? Adv Health Sci Educ T…
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psnet.ahrq.gov/node/39724/psn-pdf
July 28, 2010 - Prone to error: earliest steps to find cancer.
July 28, 2010
Saul S. New York Times. July 19, 2010;A1.
https://psnet.ahrq.gov/issue/prone-error-earliest-steps-find-cancer
This newspaper article investigates diagnostic errors in breast cancer through the story of a patient who
was misdiagnosed. Concern about the ac…
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psnet.ahrq.gov/node/47556/psn-pdf
November 28, 2018 - Improving Diagnosis.
November 28, 2018
Deutsch E, ed. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):1-70.
https://psnet.ahrq.gov/issue/improving-diagnosis
This special issue raises awareness of challenges to reducing diagnostic error. Articles discuss insights
from experts about how to improve diagnosis, t…
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psnet.ahrq.gov/node/33670/psn-pdf
July 01, 2008 - He is a leading expert on several aspects of patient safety, including
disclosure and evaluation.