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psnet.ahrq.gov/issue/another-surgeons-error-must-you-tell-patient
October 02, 2013 - Commentary
Another surgeon's error: must you tell the patient?
Citation Text:
Moffatt-Bruce SD, Denlinger CE, Sade RM. Another surgeon's error: must you tell the patient? Ann Thorac Surg. 2014;98(2):396-401. doi:10.1016/j.athoracsur.2014.04.073.
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psnet.ahrq.gov/issue/hospitals-tackle-high-risk-drugs-reduce-errors
October 07, 2015 - August 5, 2009
MGH halts a pediatric program: Heart surgeries on hold after errors.
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psnet.ahrq.gov/node/33640/psn-pdf
September 01, 2006 - increased, and yet the cost of caring for each veteran
declined dramatically.(6) What lessons does this hold
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psnet.ahrq.gov/node/49389/psn-pdf
February 01, 2003 - the insufflation needle, it is important for the assistant to “tent up” the abdominal wall and
to hold
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psnet.ahrq.gov/issue/maternal-sleepiness-and-risk-infant-drops-postpartum-period
October 19, 2022 - Study
Maternal sleepiness and risk of infant drops in the postpartum period.
Citation Text:
Bittle MD, Knapp H, Polomano RC, et al. Maternal Sleepiness and Risk of Infant Drops in the Postpartum Period. Jt Comm J Qual Patient Saf. 2019;45(5):337-347. doi:10.1016/j.jcjq.2018.12.001.
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psnet.ahrq.gov/issue/impact-mobile-technology-teamwork-and-communication-hospitals-systematic-review
January 29, 2020 - Review
Emerging Classic
The impact of mobile technology on teamwork and communication in hospitals: a systematic review.
Citation Text:
Martin G, Khajuria A, Arora S, et al. The impact of mobile technology on teamwork and communication in hospitals: a systematic…
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psnet.ahrq.gov/issue/accountability-medical-error-moving-beyond-blame-advocacy
December 19, 2018 - Review
Accountability for medical error: moving beyond blame to advocacy.
Citation Text:
Bell SK, Delbanco T, Anderson-Shaw L, et al. Accountability for medical error: moving beyond blame to advocacy. Chest. 2011;140(2):519-526. doi:10.1378/chest.10-2533.
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - The NPSGs are safety standards that hold hospital and healthcare workers accountable to best practices
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psnet.ahrq.gov/issue/decreasing-prescribing-errors-antimicrobial-stewardship-program-restricted-medications
September 25, 2024 - Study
Decreasing prescribing errors in antimicrobial stewardship program-restricted medications.
Citation Text:
Tang KM, Lee P, Anosike BI, et al. Decreasing prescribing errors in antimicrobial stewardship program-restricted medications. Hosp Pediatr. 2024;14(4):281-290. doi:10.1542/hped…
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psnet.ahrq.gov/periodic-issue/periodic-issue-463
October 30, 2024 - Artificial intelligence-based clinical decision support systems (AI-CDSS) hold promise for improving … Artificial intelligence-based clinical decision support systems (AI-CDSS) hold promise for improving
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psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
June 24, 2020 - wrong, health care culture often zeroes in on people at the " sharp end " who, for once, failed to hold
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - In Conversation with...James L. Reinertsen, MD
August 1, 2007
In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting
firm …
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psnet.ahrq.gov/issue/err-human-report-and-patient-safety-literature
November 16, 2022 - Review
The "To Err Is Human Report" and the patient safety literature.
Citation Text:
Stelfox HT, Palmisani S, Scurlock C, et al. The "To Err is Human" report and the patient safety literature. Qual Saf Health Care. 2006;15(3):174-8.
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psnet.ahrq.gov/issue/reflection-adverse-event-disclosure-postsurgical-hospital-context
August 20, 2018 - Commentary
Reflection on adverse event disclosure in the postsurgical hospital context.
Citation Text:
Roberts F, Gettings P, Torbeck L, et al. Reflection on adverse event disclosure in the postsurgical hospital context. J Surg Educ. 2015;72(4):767-70. doi:10.1016/j.jsurg.2014.12.016.
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psnet.ahrq.gov/issue/using-healthcare-failure-mode-and-effect-analysis-prospective-medication-safety-risk
June 05, 2024 - Study
Using Healthcare Failure Mode and Effect Analysis in prospective medication safety risk management in secondary care inpatient wards.
Citation Text:
Sova PM, Holmström A-R, Airaksinen M, et al. Using Healthcare Failure Mode and Effect Analysis in prospective medication safety risk …
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psnet.ahrq.gov/issue/do-calculation-errors-nurses-cause-medication-errors-clinical-practice-literature-review
December 14, 2016 - Review
Do calculation errors by nurses cause medication errors in clinical practice? A literature review.
Citation Text:
Wright K. Do calculation errors by nurses cause medication errors in clinical practice? A literature review. Nurse Educ Today. 2010;30(1):85-97. doi:10.1016/j.nedt.2…
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psnet.ahrq.gov/issue/resident-physicians-clinical-training-and-error-rate-roles-autonomy-consultation-and
July 13, 2010 - Study
Resident physicians' clinical training and error rate: the roles of autonomy, consultation, and familiarity with the literature.
Citation Text:
Naveh E, Katz-Navon T, Stern Z. Resident physicians' clinical training and error rate: the roles of autonomy, consultation, and familiarit…
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psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
September 15, 2024 - Retained Surgical Items: Definition and Epidemiology.
Citation Text:
Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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…
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psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - First, many of these requirements are intended to
hold health care facilities accountable for weaknesses … Accountability
State systems do not punish facilities for events but do seek to hold them accountable
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psnet.ahrq.gov/issue/relation-between-malpractice-claims-and-adverse-events-due-negligence-results-harvard-medical
February 18, 2011 - Study
Classic
Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III.
Citation Text:
Localio AR, Lawthers AG, Brennan TA, et al. Relation between Malpractice Claims and Adverse Events Due to …