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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44909/psn-pdf
    March 23, 2016 - Root Cause Analysis Workbook for Community/Ambulatory Pharmacy. March 23, 2016 Horsham, PA: Institute for Safe Medication Practices; 2013. https://psnet.ahrq.gov/issue/root-cause-analysis-workbook-communityambulatory-pharmacy Root cause analysis offers a structured way to detect and address system weaknesses. This…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836935/psn-pdf
    April 13, 2019 - Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition. April 13, 2019 Oakes D. Milwaukee, WI: ASQ Quality Press; 2019. ISBN: 9780873899826. https://psnet.ahrq.gov/issue/root-cause-analysis-core-problem-solving-and-corrective-action-second-edition Root cause analysis is a widely use…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46241/psn-pdf
    January 30, 2018 - Interventions to improve oral chemotherapy safety and quality: a systematic review. January 30, 2018 Zerillo JA, Goldenberg BA, Kotecha RR, et al. Interventions to Improve Oral Chemotherapy Safety and Quality. JAMA Oncol. 2017;4(1):105-117. doi:10.1001/jamaoncol.2017.0625. https://psnet.ahrq.gov/issue/intervention…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42506/psn-pdf
    August 28, 2013 - Foundations for teaching surgeons to address the contributions of systems to operating room team conflict. August 28, 2013 Rogers DA, Lingard LA, Boehler ML, et al. Foundations for teaching surgeons to address the contributions of systems to operating room team conflict. Am J Surg. 2013;206(3):428-32. doi:10.1016/…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853076/psn-pdf
    August 30, 2023 - Hospital bosses ignored months of doctors' warnings about Lucy Letby. August 30, 2023 Moritz J, Coffey J, Buchanan M. BBC News. August 19, 2023. https://psnet.ahrq.gov/issue/hospital-bosses-ignored-months-doctors-warnings-about-lucy-letby Whistleblowers can identify the presence of systemic failures, but the organ…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43000/psn-pdf
    March 05, 2014 - Elective surgical patients' narratives of hospitalization: the co-construction of safety. March 5, 2014 DOHERTY CAROLE, Saunders MNK. Elective surgical patients' narratives of hospitalization: the co- construction of safety. Soc Sci Med. 2013;98:29-36. doi:10.1016/j.socscimed.2013.08.014. https://psnet.ahrq.gov/is…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40362/psn-pdf
    April 13, 2011 - Role of clinical context in residents' physical examination diagnostic accuracy. April 13, 2011 Sibbald M, Panisko D, Cavalcanti RB. Role of clinical context in residents' physical examination diagnostic accuracy. Med Educ. 2011;45(4):415-21. doi:10.1111/j.1365-2923.2010.03896.x. https://psnet.ahrq.gov/issue/role-…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41554/psn-pdf
    January 03, 2017 - Using root cause analysis to reduce falls with injury in community settings. January 3, 2017 Lee A, Mills PD, Neily J. Using root cause analysis to reduce falls with injury in community settings. Jt Comm J Qual Patient Saf. 2012;38(8):366-374. https://psnet.ahrq.gov/issue/using-root-cause-analysis-reduce-falls-inj…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44139/psn-pdf
    June 10, 2015 - In situ simulated cardiac arrest exercises to detect system vulnerabilities. June 10, 2015 Barbeito A, Bonifacio AS, Holtschneider M, et al. In situ simulated cardiac arrest exercises to detect system vulnerabilities. Simul Healthc. 2015;10(3):154-62. doi:10.1097/SIH.0000000000000087. https://psnet.ahrq.gov/issue/…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38638/psn-pdf
    May 20, 2009 - The preliminary development and testing of a global trigger tool to detect error and patient harm in primary- care records. May 20, 2009 de Wet C, Bowie P. The preliminary development and testing of a global trigger tool to detect error and patient harm in primary-care records. Postgrad Med J. 2009;85(1002):176-80…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73447/psn-pdf
    June 30, 2021 - Errors in adult trauma resuscitation: a systematic review. June 30, 2021 Nikouline A, Quirion A, Jung JJ, et al. Errors in adult trauma resuscitation: a systematic review. CJEM. 2021;23:537–546. doi:10.1007/s43678-021-00118-7. https://psnet.ahrq.gov/issue/errors-adult-trauma-resuscitation-systematic-review Trauma …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40064/psn-pdf
    July 08, 2013 - Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project. July 8, 2013 Health Research and Educational Trust. Chicago, IL: American Hospital Association; 2010. https://psnet.ahrq.gov/issue/hand-hygiene-project-best-practices-hospitals-part…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39436/psn-pdf
    October 25, 2013 - HealthGrades Seventh Annual Patient Safety in American Hospitals Study. October 25, 2013 Golden, CO: HealthGrades, Inc.; March 2010. https://psnet.ahrq.gov/issue/healthgrades-seventh-annual-patient-safety-american-hospitals-study This report, the latest in an annual series, uses the Agency for Healthcare Research …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44339/psn-pdf
    July 29, 2015 - Rapid response systems: a systematic review and meta- analysis. July 29, 2015 Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care. 2015;19(1). doi:10.1186/s13054-015-0973-y. https://psnet.ahrq.gov/issue/rapid-response-systems-systematic-review-and-meta-analysis…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43887/psn-pdf
    April 08, 2018 - Types of diagnostic errors in neurological emergencies in the emergency department. April 8, 2018 Dubosh NM, Edlow JA, Lefton M, et al. Types of diagnostic errors in neurological emergencies in the emergency department. Diagnosis (Berl). 2015;2(1):21-28. doi:10.1515/dx-2014-0040. https://psnet.ahrq.gov/issue/types…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40294/psn-pdf
    September 24, 2016 - Hospital doctors' workflow interruptions and activities: an observation study. September 24, 2016 Weigl M, Müller A, Zupanc A, et al. Hospital doctors' workflow interruptions and activities: an observation study. BMJ Qual Saf. 2011;20(6):491-7. doi:10.1136/bmjqs.2010.043281. https://psnet.ahrq.gov/issue/hospital-d…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72805/psn-pdf
    March 03, 2021 - When machine learning goes off the rails. A guide to managing the risks. March 3, 2021 Babic B, Cohen IG,  Evgeniou T, et al. Harv Bus Rev.  2021 January/February;99(1):76- 84. https://psnet.ahrq.gov/issue/when-machine-learning-goes-rails-guide-managing-risks  This article discusses how machine lea…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41552/psn-pdf
    August 01, 2012 - Computerised provider order entry and residency education in an academic medical centre. August 1, 2012 Wong BM, Kuper A, Robinson N, et al. Computerised provider order entry and residency education in an academic medical centre. Med Educ. 2012;46(8):795-806. doi:10.1111/j.1365-2923.2012.04317.x. https://psnet.ahr…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39169/psn-pdf
    December 09, 2009 - Exploring the concept of medication discrepancy within the context of patient safety to improve population health. December 9, 2009 Murphy CR, Corbett CL, Setter SM, et al. Exploring the concept of medication discrepancy within the context of patient safety to improve population health. ANS Adv Nurs Sci. 2009;32(4)…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44717/psn-pdf
    February 10, 2016 - Trends and patterns in reporting of patient safety situations in transplantation. February 10, 2016 Stewart DE, Tlusty SM, Taylor KH, et al. Trends and Patterns in Reporting of Patient Safety Situations in Transplantation. Am J Transplant. 2015;15(12):3123-33. doi:10.1111/ajt.13528. https://psnet.ahrq.gov/issue/tr…
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