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psnet.ahrq.gov/issue/emperors-new-clothes-or-whatever-happened-human-error
March 27, 2005 - February 17, 2019
Triggers and Targeted Injury Detection Systems (TIDS) Expert Panel
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psnet.ahrq.gov/issue/enteral-feeding-misconnections-consortium-position-statement
June 17, 2009 - for tubing misconnections when using luer-tip connectors: a statement by the USP Safe Medication Use Expert
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psnet.ahrq.gov/issue/rapid-response-systems-0
April 07, 2010 - safety: health economic considerations for rapid response systems-a rapid review of the literature and expert
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psnet.ahrq.gov/issue/roadmap-health-care-safety-massachusetts
June 15, 2016 - the Same Author(s)
Advancing Patient Safety in Cataract Surgery: A Betsy Lehman Center Expert
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psnet.ahrq.gov/issue/texas-health-presbyterian-hospital-ebola-crisis-perfect-storm-human-errors-system-failures
February 23, 2018 - Copy Citation
Related Resources From the Same Author(s)
The Expert Panel
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psnet.ahrq.gov/issue/can-ai-help-doctors-come-better-diagnoses
October 07, 2015 - March 23, 2009
View More
Related Resources
Hidden flaws behind expert-level
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psnet.ahrq.gov/issue/rethinking-rapid-response-teams
February 23, 2019 - 2014
Guidelines for opioid prescribing in children and adolescents after surgery: an expert
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psnet.ahrq.gov/issue/wrong-site-surgery
March 13, 2013 - January 17, 2019
Advancing Patient Safety in Cataract Surgery: A Betsy Lehman Center Expert
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - In the absence of expert skills, heuristics are remarkably effective in helping us reach a correct diagnosis … An alternative approach is to use an algorithm that simulates expert thinking. … misread chest x-ray reflects a widespread "systems" flaw, where ED staff read chest x-rays instead of expert … Always strive to achieve expert skills through learning.
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - In the absence of expert skills, heuristics are
remarkably effective in helping us reach a correct diagnosis … An alternative approach is to use an algorithm that simulates expert thinking. … misread chest x-ray reflects a widespread "systems" flaw, where ED
staff read chest x-rays instead of expert … Always strive to achieve expert skills through learning.
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psnet.ahrq.gov/node/852698/psn-pdf
August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to
Increase Safety and Diagnostic Accuracy Innovation
August 30, 2023
https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-
diagnostic-accuracy
Summary
Addressing diagnostic errors to improve outcomes and patient safety h…
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psnet.ahrq.gov/node/33707/psn-pdf
February 01, 2011 - The University of Texas System Clinical Safety and
Effectiveness Course
February 1, 2011
Thomas EJ, Patterson JE, Martin S, et al. The University of Texas System Clinical Safety and
Effectiveness Course. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiv…
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psnet.ahrq.gov/youtube
Introducing Curated Libraries
Curated Libraries are groupings of PSNet content, curated by AHRQ and by other experts in the patient safety field. Watch the video below to learn more about how this new feature works and how it can be of benefit to you.
Visit Curated Libraries
Audio-Described Version (…
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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.
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psnet.ahrq.gov/node/33765/psn-pdf
April 01, 2014 - We
appointed a volunteer, Blue Ribbon Expert Panel of foremost experts in patient safety; they convened … At the advice of our Blue Ribbon Expert
Panel, we revised our methodology over time after some very
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psnet.ahrq.gov/node/37043/psn-pdf
May 04, 2015 - To reduce risks, hospitals enlist 'proceduralists.'
May 4, 2015
Landro L.
https://psnet.ahrq.gov/issue/reduce-risks-hospitals-enlist-proceduralists
This article reports on hospitals that are creating dedicated teams of experts who have the skills to
perform risky medical procedures.
https://psnet.ahrq.gov/issue/r…
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psnet.ahrq.gov/node/34986/psn-pdf
December 10, 2008 - Buried answers.
December 10, 2008
Dobbs D. New York Times. April 24, 2005.
https://psnet.ahrq.gov/issue/buried-answers
The author interviews experts who discuss the autopsy as a unique method for discovering medical
mistakes and why it is not used more often as a teaching and improvement mechanism.
https://psnet.…
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psnet.ahrq.gov/node/34131/psn-pdf
March 07, 2005 - Safetyleaders.org
March 7, 2005
Texas Medical Institute of Technology
https://psnet.ahrq.gov/issue/safetyleadersorg
Safetyleaders.org is a knowledge management system provided to hospital leaders and performance
experts. Portions of the site are not accessible to individuals whose organizations are not actively in…
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psnet.ahrq.gov/node/42771/psn-pdf
January 08, 2014 - Patient Safety Collaboration.
January 8, 2014
National Quality Forum; NQF.
https://psnet.ahrq.gov/issue/patient-safety-collaboration
This program aligns with the Partnership for Patients to engage patients, reduce readmissions, and
improve safety in maternity care by convening experts and developing best practices…
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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…