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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/858173/psn-pdf
    December 13, 2023 - Measurement of ambulatory medication errors in children: a scoping review. December 13, 2023 Rickey L, Auger K, Britto MT, et al. Measurement of ambulatory medication errors in children: a scoping review. Pediatrics. 2023;152(6):e2023061281. doi:10.1542/peds.2023-061281. https://psnet.ahrq.gov/issue/measurement-am…

  3. 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-…

  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/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…

  6. 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…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44617/psn-pdf
    January 22, 2016 - Pediatric prehospital medication dosing errors: a mixed- methods study. January 22, 2016 Hoyle JD, Sleight D, Henry R, et al. Pediatric prehospital medication dosing errors: a mixed-methods study. Prehosp Emerg Care. 2016;20(1):117-124. doi:10.3109/10903127.2015.1061625. https://psnet.ahrq.gov/issue/pediatric-preh…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848044/psn-pdf
    April 26, 2023 - Effect of a hospital command centre on patient safety: an interrupted time series study. April 26, 2023 Mebrahtu TF, McInerney CD, Benn J, et al. BMJ Health Care Inform. 2023;30(1):e100653. https://psnet.ahrq.gov/issue/effect-hospital-command-centre-patient-safety-interrupted-time-series-study Command centers…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47749/psn-pdf
    June 19, 2019 - A simulation-based approach to training in heuristic clinical decision-making. June 19, 2019 Altabbaa G, Raven AD, Laberge J. A simulation-based approach to training in heuristic clinical decision- making. Diagnosis (Berl). 2019;6(2):91-99. doi:10.1515/dx-2018-0084. https://psnet.ahrq.gov/issue/simulation-based-ap…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47712/psn-pdf
    February 20, 2019 - A cognitive forcing tool to mitigate cognitive bias—a randomised control trial. February 20, 2019 O'Sullivan ED, Schofield SJ. A cognitive forcing tool to mitigate cognitive bias - a randomised control trial. BMC Med Educ. 2019;19(1):12. doi:10.1186/s12909-018-1444-3. https://psnet.ahrq.gov/issue/cognitive-forcing…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41084/psn-pdf
    January 25, 2012 - 'Skating on thin ice?' Consultant surgeon's contemporary experience of adverse surgical events. January 25, 2012 Skevington SM, Langdon JE, Giddins G. ‘Skating on thin ice?’ Consultant surgeon's contemporary experience of adverse surgical events. Psychol Health Med. 2011;17(1). doi:10.1080/13548506.2011.592841. h…

  12. 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…

  13. 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/…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37822/psn-pdf
    June 18, 2008 - A morbidity and mortality conference-based classification system for adverse events: surgical outcome analysis: part I. June 18, 2008 Antonacci AC, Lam S, Lavarias V, et al. A morbidity and mortality conference-based classification system for adverse events: surgical outcome analysis: part I. J Surg Res. 2008;147(…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43051/psn-pdf
    May 29, 2014 - A just culture after Mid Staffordshire. May 29, 2014 Dekker SWA, Hugh TB. A just culture after Mid Staffordshire. BMJ Qual Saf. 2014;23(5):356-8. doi:10.1136/bmjqs-2013-002483. https://psnet.ahrq.gov/issue/just-culture-after-mid-staffordshire In the context of public reactions to the Francis report, this commentar…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867393/psn-pdf
    December 18, 2024 - The predictors of patient safety culture in hospital setting: a systematic review. December 18, 2024 Vibe A, Rasmussen SH, Rasmussen NOP, et al. The predictors of patient safety culture in hospital setting: a systematic review. J Patient Saf. 2024;20(8):576-592. doi:10.1097/pts.0000000000001285. https://psnet.ahrq…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38597/psn-pdf
    June 12, 2009 - A patient safety curriculum for graduate medical education: results from a needs assessment of educators and patient safety experts. June 12, 2009 Varkey P, Karlapudi S, Rose S, et al. A patient safety curriculum for graduate medical education: results from a needs assessment of educators and patient safety expert…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42582/psn-pdf
    September 18, 2013 - When diagnostic testing leads to harm: a new outcomes- based approach for laboratory medicine. September 18, 2013 Epner PL, Gans JE, Graber ML. When diagnostic testing leads to harm: a new outcomes-based approach for laboratory medicine. BMJ Qual Saf. 2013;22 Suppl 2:ii6-ii10. doi:10.1136/bmjqs-2012-001621. https:…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39559/psn-pdf
    December 17, 2010 - Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy. December 17, 2010 James L, Davies G, Kinchin I, et al. Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy. Adv Health Sci Educ Theory Pract. 2010;15(5):735-47. doi:10.1007/s10459-01…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34805/psn-pdf
    November 07, 2017 - Medication errors in neonatal and paediatric intensive- care units. November 7, 2017 Raju TN, Kecskes S, Thornton JP, et al. Medication errors in neonatal and paediatric intensive-care units. Lancet. 1989;2(8659):374-6. https://psnet.ahrq.gov/issue/medication-errors-neonatal-and-paediatric-intensive-care-units Th…
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