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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42469/psn-pdf
    August 07, 2013 - Characteristics of paid malpractice claims settled in and out of court in the USA: a retrospective analysis. August 7, 2013 Rubin JB, Bishop TF. Characteristics of paid malpractice claims settled in and out of court in the USA: a retrospective analysis. BMJ Open. 2013;3(6). doi:10.1136/bmjopen-2013-002985. https:/…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46374/psn-pdf
    August 30, 2017 - Structured patient handoffs: the movement toward adverse event reduction in the perioperative unit. August 30, 2017 Hamilton WL. https://psnet.ahrq.gov/issue/structured-patient-handoffs-movement-toward-adverse-event-reduction- perioperative-unit Miscommunication during care transitions can contribute to medical e…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857459/psn-pdf
    December 06, 2023 - Five strategies for a safer EHR modernization journey. December 6, 2023 Sittig DF, Yackel EE, Singh H. Five strategies for a safer EHR modernization journey. J Gen Intern Med. 2023;38(S4):940-942. doi:10.1007/s11606-023-08331-z. https://psnet.ahrq.gov/issue/five-strategies-safer-ehr-modernization-journey Large-sca…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60322/psn-pdf
    May 13, 2020 - Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality. May 13, 2020 Leistikow I, Bal RA. Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality. BMJ Qual Saf. 2020;29(10):869–872. doi:10.113…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44548/psn-pdf
    November 20, 2015 - Safety-II and resilience: the way ahead in patient safety in anaesthesiology. November 20, 2015 Staender S. Safety-II and resilience: the way ahead in patient safety in anaesthesiology. Curr Opin Anaesthesiol. 2015;28(6):735-9. doi:10.1097/ACO.0000000000000252. https://psnet.ahrq.gov/issue/safety-ii-and-resilience…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44521/psn-pdf
    July 03, 2016 - Crib of horrors: one hospital's approach to promoting a culture of safety. July 3, 2016 Korah N, Zavalkoff S, Dubrovsky AS. Crib of Horrors: One Hospital's Approach to Promoting a Culture of Safety. Pediatrics. 2015;136(1):4-5. doi:10.1542/peds.2014-3843. https://psnet.ahrq.gov/issue/crib-horrors-one-hospitals-app…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43971/psn-pdf
    April 25, 2016 - Why empathy may be the best risk management strategy. April 25, 2016 Hertz BT. Why empathy may be the best risk management strategy. Medical economics. 2015;92(3):40-4. https://psnet.ahrq.gov/issue/why-empathy-may-be-best-risk-management-strategy Communication and response strategies have been shown to improve how …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43294/psn-pdf
    April 25, 2016 - The right and wrong way to talk to patients about adverse events. April 25, 2016 Beaulieu-Volk D. The right and wrong way to talk to patients about adverse events. Medical economics. 2014;91(11):52-5. https://psnet.ahrq.gov/issue/right-and-wrong-way-talk-patients-about-adverse-events Apology laws have been explor…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39922/psn-pdf
    October 13, 2010 - What’s past is prologue: organizational learning from a serious patient injury. October 13, 2010 Tamuz M, Franchois KE, Thomas EJ. What’s past is prologue: Organizational learning from a serious patient injury. Saf Sci. 2010;49(1). doi:10.1016/j.ssci.2010.06.005. https://psnet.ahrq.gov/issue/whats-past-prologue-or…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43361/psn-pdf
    July 16, 2014 - An Avoidable Death of a Three-year-old Child from Sepsis. July 16, 2014 London, UK: Parliamentary and Health Service Ombudsman; June 2014. https://psnet.ahrq.gov/issue/avoidable-death-three-year-old-child-sepsis This investigation outlines how inadequate care contributed to the death of a child who developed sepsi…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45161/psn-pdf
    September 19, 2016 - Design of an evidence-based "second victim" curriculum for nurse anesthetists. September 19, 2016 Daniels RG, McCorkle R. Design of an Evidence-Based "Second Victim" Curriculum for Nurse Anesthetists. AANA J. 2016;84(2):107-113. https://psnet.ahrq.gov/issue/design-evidence-based-second-victim-curriculum-nurse-anes…

  12. Slippery Slide Into Life | PSNet

    psnet.ahrq.gov/web-mm/slippery-slide-life
    January 21, 2017 - Slippery Slide Into Life Citation Text: Halamek LP. Slippery Slide Into Life. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …

  13. EMR Entry Error: Not So Benign | PSNet

    psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
    July 01, 2012 - EMR Entry Error: Not So Benign Citation Text: Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…

  14. Recurrent Hypoglycemia: A Care Transition Failure? | PSNet

    psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
    December 23, 2020 - SPOTLIGHT CASE Recurrent Hypoglycemia: A Care Transition Failure? Citation Text: Eytan T. Recurrent Hypoglycemia: A Care Transition Failure?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format:…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46175/psn-pdf
    September 24, 2017 - Applying lessons from social psychology to transform the culture of error disclosure. September 24, 2017 Han J, LaMarra D, Vapiwala N. Applying lessons from social psychology to transform the culture of error disclosure. Med Educ. 2017;51(10):996-1001. doi:10.1111/medu.13345. https://psnet.ahrq.gov/issue/applying-…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837204/psn-pdf
    May 25, 2022 - Resident physicians' advice seeking and error making: a social networks approach. May 25, 2022 Katz-Navon T, Naveh E. Resident physicians' advice seeking and error making: a social networks approach. Health Care Manage Rev. 2022;47(3):e41-e49. doi:10.1097/hmr.0000000000000333. https://psnet.ahrq.gov/issue/resident…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47581/psn-pdf
    January 09, 2019 - Patient safety in inpatient psychiatry: a remaining frontier for health policy. January 9, 2019 Shields MC, Stewart MT, Delaney KR. Patient Safety In Inpatient Psychiatry: A Remaining Frontier For Health Policy. Health Aff (Millwood). 2018;37(11):1853-1861. doi:10.1377/hlthaff.2018.0718. https://psnet.ahrq.gov/iss…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866254/psn-pdf
    July 10, 2024 - Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. July 10, 2024 Massey W, Keith C. Spotlight PA: June 20, 2024. https://psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems- months-shutdown-then Whistleblowers…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73403/psn-pdf
    June 16, 2021 - Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA. June 16, 2021 Office of Inspector General. June 2, 2021. Report No. 18-02496-157. https://psnet.ahrq.gov/issue/pathology-oversight-failures-veterans-health-care-system-ozarks-fayetteville- arkansas-va …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43480/psn-pdf
    January 01, 2015 - Speaking up: factors and issues in nurses advocating for patients when patients are in jeopardy. December 15, 2014 Rainer J. Speaking up: factors and issues in nurses advocating for patients when patients are in jeopardy. J Nurs Care Qual. 2015;30(1):53-62. doi:10.1097/NCQ.0000000000000081. https://psnet.ahrq.gov/…
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