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psnet.ahrq.gov/issue/piece-my-mind-snakes-dock
March 15, 2016 - Commentary
A piece of my mind. Snakes on a dock.
Citation Text:
Detsky AS. Snakes on a Dock. JAMA. 2016;316(10):1043-4. doi:10.1001/jama.2016.5179.
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psnet.ahrq.gov/issue/physician-assistants-and-disclosure-medical-error
May 11, 2016 - Commentary
Physician assistants and the disclosure of medical error.
Citation Text:
Brock DM, Quella A, Lipira L, et al. Physician assistants and the disclosure of medical error. Acad Med. 2014;89(6):858-62. doi:10.1097/ACM.0000000000000261.
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psnet.ahrq.gov/issue/ny-medicaid-ups-ante-refusing-pay-14-never-events-nations-biggest-medicaid-program-could
December 16, 2009 - Newspaper/Magazine Article
NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action.
Citation Text:
NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid p…
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psnet.ahrq.gov/issue/health-care-comes-home-human-factors
June 08, 2011 - Book/Report
Health Care Comes Home: The Human Factors.
Citation Text:
Health Care Comes Home: The Human Factors. Committee on the Role of Human Factors in Home Health Care. Washington, DC: National Research Council; 2011. ISBN: 9780309212366.
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psnet.ahrq.gov/issue/disclosure-adverse-events-patients
November 29, 2023 - Organizational Policy/Guidelines
Disclosure of Adverse Events to Patients.
Citation Text:
Disclosure of Adverse Events to Patients. Department of Veterans Affairs, Washington DC: Veterans Health Administration; October 31, 2018. VHA Directive 1004.08.
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psnet.ahrq.gov/issue/weak-oversight-allows-lab-failures-put-patients-risk
June 12, 2019 - Newspaper/Magazine Article
Weak oversight allows lab failures to put patients at risk.
Citation Text:
Weak oversight allows lab failures to put patients at risk. Gabler E. Milwaukee Journal Sentinel. May 15, 2015.
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psnet.ahrq.gov/issue/check-your-medical-records-dangerous-errors
November 03, 2021 - Newspaper/Magazine Article
Check your medical records for dangerous errors.
Citation Text:
Check your medical records for dangerous errors. Graham J. Kaiser Health News. November 21, 2018.
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psnet.ahrq.gov/issue/reducing-adverse-obstetrical-outcomes-through-safety-sciences
May 30, 2018 - Review
Reducing adverse obstetrical outcomes through safety sciences.
Citation Text:
Reducing adverse obstetrical outcomes through safety sciences. Ennen CS, Satin AJ. UpToDate. October 16, 2024.
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psnet.ahrq.gov/issue/independent-review-gross-negligence-manslaughter-and-culpable-homicide
July 08, 2019 - Book/Report
Independent Review of Gross Negligence Manslaughter and Culpable Homicide.
Citation Text:
Independent Review of Gross Negligence Manslaughter and Culpable Homicide. Manchester, UK: General Medical Council; June 2019.
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psnet.ahrq.gov/issue/doctors-were-alarmed-would-i-have-my-children-have-surgery-here
February 19, 2020 - Newspaper/Magazine Article
Doctors were alarmed: would I have my children have surgery here?
Citation Text:
Doctors were alarmed: would I have my children have surgery here? Gabler E. New York Times. May 31, 2019.
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psnet.ahrq.gov/issue/partnering-improve-quality-and-safety-framework-working-patient-and-family-advisors
July 01, 2015 - Book/Report
Partnering to Improve Quality and Safety: A Framework for Working With Patient and Family Advisors.
Citation Text:
Partnering to Improve Quality and Safety: A Framework for Working With Patient and Family Advisors. Chicago, IL: Health Research & Educational Trust; 2015.
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psnet.ahrq.gov/issue/understanding-and-learning-organisational-failure
April 19, 2011 - Commentary
Understanding and learning from organisational failure.
Citation Text:
Walshe K. Understanding and learning from organisational failure. Qual Saf Health Care. 2003;12(2):81-2.
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psnet.ahrq.gov/issue/california-pharmacies-are-making-millions-mistakes-theyre-fighting-keep-secret
October 14, 2020 - Newspaper/Magazine Article
California pharmacies are making millions of mistakes. They’re fighting to keep that secret.
Citation Text:
California pharmacies are making millions of mistakes. They’re fighting to keep that secret. Peterson M. Los Angeles Times. September 5, 2023.
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psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures
November 01, 2023 - Newspaper/Magazine Article
Patient death tied to lack of proper escalation process for barcode scanning failures.
Citation Text:
Patient death tied to lack of proper escalation process for barcode scanning failures. ISMP Medication Safety Alert! Acute Care edition. 2023;28(19):1-3.
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psnet.ahrq.gov/issue/walgreens-will-stop-judging-its-pharmacy-staffers-how-fast-they-work
May 05, 2021 - Newspaper/Magazine Article
Walgreens will stop judging its pharmacy staffers by how fast they work.
Citation Text:
Walgreens will stop judging its pharmacy staffers by how fast they work. Kaplan A. NBC News. October 27, 2022.
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psnet.ahrq.gov/issue/retrievals-reveals-painful-experiences-female-patients-are-often-ignored
September 11, 2019 - Audiovisual Presentation
‘The Retrievals’ reveals painful experiences of female patients are often ignored.
Citation Text:
‘The Retrievals’ reveals painful experiences of female patients are often ignored. Desjardins L. PBS NewsHour. August 29, 2023.
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psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure
September 07, 2022 - Audiovisual Presentation
First, Do No Harm Part 1: A Case Study of Systems Failure.
Citation Text:
First, Do No Harm Part 1: A Case Study of Systems Failure. Chicago: Partnership for Patient Safety, Harvard Risk Management Foundation; 2000.
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psnet.ahrq.gov/issue/encouraging-patients-ask-questions-how-overcome-white-coat-silence
April 17, 2019 - Commentary
Encouraging patients to ask questions: how to overcome "white-coat silence."
Citation Text:
Judson TJ, Detsky AS, Press MJ. Encouraging patients to ask questions: how to overcome "white-coat silence". JAMA. 2013;309(22):2325-6. doi:10.1001/jama.2013.5797.
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psnet.ahrq.gov/issue/quest-six-sigma
January 04, 2010 - Commentary
On the quest for Six Sigma.
Citation Text:
Moorman D. On the quest for Six Sigma. Am J Surg. 2005;189(3):253-8.
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psnet.ahrq.gov/issue/we-had-such-trust-we-feel-such-fools-how-shocking-hospital-mistakes-led-our-daughters-death
October 26, 2022 - Newspaper/Magazine Article
'We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death.
Citation Text:
'We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death. Mills M. The Guardian. September 3, 2022.
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