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1981. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49836/psn-pdf
      July 01, 2018 - Primary Workaround, Secondary Complication July 1, 2018 Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication The Case A young adult with a progressive neurological disorder presented to a hospital emerg…

1982. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33629/psn-pdf
      March 01, 2006 - What Does Simulation Add to Teamwork Training? March 1, 2006 Gaba DM. What Does Simulation Add to Teamwork Training? PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training Editor's Note: In these point–counterpoint articles, Drs. Pratt and Sachs of Beth Israel Deacones…

1983. DNR in the OR and Afterwards | PSNet
      psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
      July 01, 2003 - DNR in the OR and Afterwards Citation Text: Lo B. DNR in the OR and Afterwards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…

1984. Near Miss With Neonate | PSNet
      psnet.ahrq.gov/web-mm/near-miss-neonate
      August 15, 2018 - Near Miss With Neonate Citation Text: Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

1985. The Magnetic Deflection | PSNet
      psnet.ahrq.gov/web-mm/magnetic-deflection
      November 18, 2016 - The Magnetic Deflection Citation Text: Kanal E. The Magnetic Deflection. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…

1986. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41397/psn-pdf
      June 06, 2012 - Semi-supervised classification of patient safety event reports. June 6, 2012 McKnight SD. Semi-supervised classification of patient safety event reports. J Patient Saf. 2012;8(2):60-4. doi:10.1097/PTS.0b013e31824ab987. https://psnet.ahrq.gov/issue/semi-supervised-classification-patient-safety-event-reports This s…

1987. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49584/psn-pdf
      April 01, 2009 - EMR Entry Error: Not So Benign April 1, 2009 Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign The Case A 47-year-old man with advanced AIDS was admitted to an academic medical center with a chief complaint of shortness of breath. He was …

1988. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33663/psn-pdf
      September 15, 2008 - Implementing a Patient Safety Program at a Large National Health System January 1, 2008 Hauck LD, Jacob J. Implementing a Patient Safety Program at a Large National Health System. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system Perspectiv…

1989. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49570/psn-pdf
      October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure? October 1, 2008 Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure Case Objectives Understand the complementary abilities of an electronic health record a…

1990. Medication Mix-Up: From Bad to Worse | PSNet
      psnet.ahrq.gov/web-mm/medication-mix-bad-worse
      March 01, 2018 - Medication Mix-Up: From Bad to Worse Citation Text: Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote …

1991. The Case of Mistaken Intubation | PSNet
      psnet.ahrq.gov/web-mm/case-mistaken-intubation
      July 01, 2016 - SPOTLIGHT CASE The Case of Mistaken Intubation Citation Text: Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX End…

1992. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854642/psn-pdf
      October 18, 2023 - Cybersecurity for the Clinician. October 18, 2023 Chicago, IL: American Medical Association; 2023. https://psnet.ahrq.gov/issue/cybersecurity-clinician The vulnerability of healthcare information technologies and devices to malicious interruptions is increasingly recognized as a patient safety hazard. This eight-e…

1993. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73552/psn-pdf
      August 04, 2021 - To err is human, to apologize is hard. August 4, 2021 Krakower TM. To err Is human, to apologize is hard. JAMA. 2021;326(3):223-224. doi:10.1001/jama.2021.10840. https://psnet.ahrq.gov/issue/err-human-apologize-hard Disclosure and apology are two related actions that aid in rebuilding trust between clinicians, pat…

1994. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43017/psn-pdf
      June 12, 2019 - Saying Sorry. June 12, 2019 London, England: NHS Resolution; 2018. https://psnet.ahrq.gov/issue/saying-sorry Although victims of adverse events have clearly expressed their preferences for full error disclosure, most physicians remain uncomfortable with disclosing and apologizing for errors. This leaflet offers in…

1995. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39585/psn-pdf
      June 09, 2010 - Bar code technology and medication administration error. June 9, 2010 Young J, Slebodnik M, Sands L. Bar Code Technology and Medication Administration Error. J Patient Saf. 2010;6(2):115-120. doi:10.1097/pts.0b013e3181de35f7. https://psnet.ahrq.gov/issue/bar-code-technology-and-medication-administration-error This…

1996. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39752/psn-pdf
      September 09, 2010 - Ambulance personnel perceptions of near misses and adverse events in pediatric patients. September 9, 2010 Cushman JT, Fairbanks RJ, O'Gara KG, et al. Ambulance personnel perceptions of near misses and adverse events in pediatric patients. Prehosp Emerg Care. 2010;14(4):477-84. doi:10.3109/10903127.2010.497901. h…

1997. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841199/psn-pdf
      December 07, 2022 - Press Play on Safety Conversations. December 7, 2022 Healthcare Excellence Canada. 2022. https://psnet.ahrq.gov/issue/press-play-safety-conversations After a patient safety incident, effective discussions are critical for healing and improvement. This website houses collections of materials to support constructive…

1998. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37485/psn-pdf
      June 29, 2011 - Perceptions of preventable medical errors in Alberta, Canada. June 29, 2011 Northcott H, Vanderheyden L, Northcott J, et al. Perceptions of preventable medical errors in Alberta, Canada. Int J Qual Health Care. 2007;20(2):115-122. doi:10.1093/intqhc/mzm067. https://psnet.ahrq.gov/issue/perceptions-preventable-medi…

1999. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853250/psn-pdf
      September 06, 2023 - ‘The Retrievals’ reveals painful experiences of female patients are often ignored. September 6, 2023 Desjardins L. PBS NewsHour. August 29, 2023. https://psnet.ahrq.gov/issue/retrievals-reveals-painful-experiences-female-patients-are-often-ignored Disregard for women’s pain is a persistent problem in health care. …

2000. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39715/psn-pdf
      May 25, 2011 - Barriers to incident notification in a regional prehospital setting. May 25, 2011 Jennings PA, Stella J. Barriers to incident notification in a regional prehospital setting. Emerg Med J. 2011;28(6):526-9. doi:10.1136/emj.2010.090738. https://psnet.ahrq.gov/issue/barriers-incident-notification-regional-prehospital-…