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4901. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35830/psn-pdf
      July 22, 2010 - EMS helicopter crashes: what influences fatal outcome? July 22, 2010 Baker SP, Grabowski JG, Dodd RS, et al. EMS helicopter crashes: what influences fatal outcome? Ann Emerg Med. 2006;47(4):351-356. https://psnet.ahrq.gov/issue/ems-helicopter-crashes-what-influences-fatal-outcome The authors studied data on emerge…

4902. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38978/psn-pdf
      January 04, 2010 - Unintended exposure in radiotherapy: identification of prominent causes. January 4, 2010 Boadu M, Rehani MM. Unintended exposure in radiotherapy: identification of prominent causes. Radiother Oncol. 2009;93(3):609-17. doi:10.1016/j.radonc.2009.08.044. https://psnet.ahrq.gov/issue/unintended-exposure-radiotherapy-i…

4903. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41977/psn-pdf
      October 11, 2016 - Patient safety tool helps ID hospital errors. October 11, 2016 Clark C. HealthLeaders Media. December 2012. https://psnet.ahrq.gov/issue/patient-safety-tool-helps-id-hospital-errors This magazine article discusses how the AHRQ common formats tool has been used to identify, track, and report near misses in hospital…

4904. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36408/psn-pdf
      December 22, 2010 - Development of a rating system for surgeons' non- technical skills. December 22, 2010 Yule S, Flin R, Paterson-Brown S, et al. Development of a rating system for surgeons' non-technical skills. Med Educ. 2006;40(11):1098-104. https://psnet.ahrq.gov/issue/development-rating-system-surgeons-non-technical-skills The…

4905. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40452/psn-pdf
      May 11, 2011 - The novice nurse and clinical decision-making: how to avoid errors. May 11, 2011 Saintsing D, Gibson LM, Pennington AW. The novice nurse and clinical decision-making: how to avoid errors. J Nurs Manag. 2011;19(3):354-9. doi:10.1111/j.1365-2834.2011.01248.x. https://psnet.ahrq.gov/issue/novice-nurse-and-clinical-de…

4906. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35787/psn-pdf
      July 01, 2009 - Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. July 1, 2009 Rockville MD: Center for Devices and Radiological Health, Food and Drug Administration; 2006. https://psnet.ahrq.gov/issue/hospital-bed-system-dimensional-and-assessment-guidance-reduce- entrapment This document provides ba…

4907. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35944/psn-pdf
      August 02, 2010 - Analysis of laboratory critical value reporting at a large academic medical center. August 2, 2010 Dighe AS, Rao A, Coakley AB, et al. Analysis of laboratory critical value reporting at a large academic medical center. Am J Clin Pathol. 2006;125(5):758-64. https://psnet.ahrq.gov/issue/analysis-laboratory-critical-…

4908. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41950/psn-pdf
      September 24, 2016 - Distraction and interruption in anaesthetic practice. September 24, 2016 Campbell G, Arfanis K, Smith AF. Distraction and interruption in anaesthetic practice. Br J Anaesth. 2012;109(5):707-715. doi:10.1093/bja/aes219. https://psnet.ahrq.gov/issue/distraction-and-interruption-anaesthetic-practice Finding that inte…

4909. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36831/psn-pdf
      February 15, 2010 - The medicolegal aspect of error in pathology: a search of jury verdicts and settlements. February 15, 2010 Kornstein MJ, Byrne SP. The medicolegal aspect of error in pathology: a search of jury verdicts and settlements. Arch Pathol Lab Med. 2007;131(4):615-618. https://psnet.ahrq.gov/issue/medicolegal-aspect-error…

4910. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38146/psn-pdf
      March 04, 2011 - Advancing measurement of patient safety culture. March 4, 2011 Ginsburg LR, Gilin D, Tregunno D, et al. Advancing measurement of patient safety culture. Health Serv Res. 2009;44(1):205-24. doi:10.1111/j.1475-6773.2008.00908.x. https://psnet.ahrq.gov/issue/advancing-measurement-patient-safety-culture Analysis of re…

4911. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37503/psn-pdf
      January 06, 2017 - Addressing postdischarge adverse events: a neglected area. January 6, 2017 Tsilimingras D. Addressing postdischarge adverse events: a neglected area. Jt Comm J Qual Patient Saf. 2008;34(2):85-97. https://psnet.ahrq.gov/issue/addressing-postdischarge-adverse-events-neglected-area This review examined the literatur…

4912. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41179/psn-pdf
      February 29, 2012 - High fidelity simulation as a research tool. February 29, 2012 Littlewood KE. High fidelity simulation as a research tool. Best Pract Res Clin Anaesthesiol. 2011;25(4):473-87. doi:10.1016/j.bpa.2011.08.001. https://psnet.ahrq.gov/issue/high-fidelity-simulation-research-tool This review explores simulation as a met…

4913. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73104/psn-pdf
      January 04, 2021 - patient harm events into healthcare systems and a human factors lens can be particularly useful for identifying

4914. The generalizability of a medication administration discrepancy detection system: quantitative comparative analysis | PSNet
      psnet.ahrq.gov/innovation/generalizability-medication-administration-discrepancy-detection-system-quantitative
      November 04, 2020 - EMERGING INNOVATIONS The generalizability of a medication administration discrepancy detection system: quantitative comparative analysis Citation Text: Kirkendall E, Huth H, Rauenbuehler B, et al. The generalizability of a medication administration discrepancy detection system: quantitative compar…

4915. EHR Copy and Paste and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
      January 01, 2018 - demonstrated a relationship between copy and paste and clinical outcomes.( 5 ) The first was focused on identifying … around this issue.( 10-12 ) In the technology realm, a few vendors have developed tools for easily identifying

4916. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38267/psn-pdf
      December 03, 2008 - National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare. December 3, 2008 National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194. https://psnet.ahrq.gov/issue/national-priorities-and-goals-aligning-our-efforts-transform-americas-healthcare This…

4917. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41592/psn-pdf
      August 15, 2012 - Failure mode and effects analysis outputs: are they valid? August 15, 2012 Shebl NA, Franklin BD, Barber N. Failure mode and effects analysis outputs: are they valid? BMC Health Serv Res. 2012;12:150. doi:10.1186/1472-6963-12-150. https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-outputs-are-they-valid…

4918. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35366/psn-pdf
      September 27, 2016 - Certified pharmacy technicians' views on their medication preparation errors and educational needs. September 27, 2016 Desselle SP. Certified pharmacy technicians' views on their medication preparation errors and educational needs. Am J Health Syst Pharm. 2005;62(19):1992-7. https://psnet.ahrq.gov/issue/certified-…

4919. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39317/psn-pdf
      November 02, 2010 - Exploring the causes of adverse events in hospitals and potential prevention strategies. November 2, 2010 Smits M, Zegers M, Groenewegen PP, et al. Exploring the causes of adverse events in hospitals and potential prevention strategies. BMJ Qual Saf. 2010;19(5). doi:10.1136/qshc.2008.030726. https://psnet.ahrq.gov…

4920. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41508/psn-pdf
      July 11, 2012 - Complications in surgery: root cause analysis and preventive measures. July 11, 2012 Chung KC, Kotsis S. Complications in surgery: root cause analysis and preventive measures. Plast Reconstr Surg. 2012;129(6):1421-1427. doi:10.1097/PRS.0b013e31824ecda0. https://psnet.ahrq.gov/issue/complications-surgery-root-cause…