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psnet.ahrq.gov/node/45837/psn-pdf
March 08, 2017 - Promoting civility in the OR: an ethical imperative.
March 8, 2017
Clark CM, Kenski D. Promoting Civility in the OR: An Ethical Imperative. AORN J. 2017;105(1):60-66.
doi:10.1016/j.aorn.2016.10.019.
https://psnet.ahrq.gov/issue/promoting-civility-or-ethical-imperative
The operating room is a complex environment th…
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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…
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psnet.ahrq.gov/node/35704/psn-pdf
March 28, 2011 - Relationship between patient complaints and surgical
complications.
March 28, 2011
Murff HJ, France DJ, Blackford J, et al. Relationship between patient complaints and surgical
complications. Qual Saf Health Care. 2006;15(1):13-6.
https://psnet.ahrq.gov/issue/relationship-between-patient-complaints-and-surgical-co…
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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…
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psnet.ahrq.gov/node/44121/psn-pdf
May 13, 2015 - Educating medical trainees on medication reconciliation:
a systematic review.
May 13, 2015
Ramjaun A, Sudarshan M, Patakfalvi L, et al. Educating medical trainees on medication reconciliation: a
systematic review. BMC Med Educ. 2015;15:33. doi:10.1186/s12909-015-0306-5.
https://psnet.ahrq.gov/issue/educating-medic…
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psnet.ahrq.gov/node/837336/psn-pdf
June 08, 2022 - Automated identification of diagnostic labelling errors in
medicine.
June 8, 2022
Hautz WE, Kündig MM, Tschanz R, et al. Automated identification of diagnostic labelling errors in medicine.
Diagnosis. 2021;9(2):241-249. doi:10.1515/dx-2021-0039.
https://psnet.ahrq.gov/issue/automated-identification-diagnostic-labe…
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psnet.ahrq.gov/node/36132/psn-pdf
May 27, 2011 - Motion study in surgery.
May 27, 2011
Gilbreth FB. Can J Med Surg. 1916:22-31.
https://psnet.ahrq.gov/issue/motion-study-surgery
This study was one of the first "time-motion" studies of physicians, and pioneered the application of human
factors engineering and industrial principles to medical practice. The authors…
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psnet.ahrq.gov/node/42574/psn-pdf
December 21, 2014 - Physicians' diagnostic accuracy, confidence, and
resource requests: a vignette study.
December 21, 2014
Meyer AND, Payne VL, Meeks DW, et al. Physicians' diagnostic accuracy, confidence, and resource
requests: a vignette study. JAMA Intern Med. 2013;173(21):1952-1958.
doi:10.1001/jamainternmed.2013.10081.
https:/…
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psnet.ahrq.gov/node/41453/psn-pdf
November 26, 2014 - Judging whether a patient is actually improving: more
pitfalls from the science of human perception.
November 26, 2014
Redelmeier DA, Dickinson VM. Judging whether a patient is actually improving: more pitfalls from the
science of human perception. J Gen Intern Med. 2012;27(9):1195-9. doi:10.1007/s11606-012-2097-2.…
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psnet.ahrq.gov/node/44095/psn-pdf
May 13, 2015 - Retained foreign bodies: risk and outcomes at the
national level.
May 13, 2015
Al-Qurayshi ZH, Hauch AT, Slakey DP, et al. Retained foreign bodies: risk and outcomes at the national
level. J Am Coll Surg. 2015;220(4):749-759. doi:10.1016/j.jamcollsurg.2014.12.015.
https://psnet.ahrq.gov/issue/retained-foreign-bodi…
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psnet.ahrq.gov/node/73256/psn-pdf
May 12, 2021 - Addiction treatment providers in Pa. face little state
scrutiny despite harm to clients.
May 12, 2021
Pattani A, Mahon E. Kaiser Health News. April 30, 2021.
https://psnet.ahrq.gov/issue/addiction-treatment-providers-pa-face-little-state-scrutiny-despite-harm-clients
Systemic oversight weaknesses and lack of…
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psnet.ahrq.gov/node/44281/psn-pdf
July 22, 2015 - Surgeon Scorecard.
July 22, 2015
Wei S; Allen M; Pierce O.
https://psnet.ahrq.gov/issue/surgeon-scorecard
Transparency has been advocated as a key element of safe, patient-centered care, but data on individual
performance has not been made widely available. This database compiles the death and complication
rates …
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psnet.ahrq.gov/node/43120/psn-pdf
September 27, 2016 - How studying human factors improves patient safety.
September 27, 2016
Eggertson L. How studying human factors improves patient safety. The Canadian nurse. 2014;110(2):25-9.
https://psnet.ahrq.gov/issue/how-studying-human-factors-improves-patient-safety
Human factors engineering is being increasingly promoted as an…
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psnet.ahrq.gov/node/47512/psn-pdf
February 20, 2019 - Framing the challenges of artificial intelligence in
medicine.
February 20, 2019
Yu K-H, Kohane IS. Framing the challenges of artificial intelligence in medicine. BMJ Qual Saf.
2019;28(3):238-241. doi:10.1136/bmjqs-2018-008551.
https://psnet.ahrq.gov/issue/framing-challenges-artificial-intelligence-medicine
Use o…
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psnet.ahrq.gov/node/867650/psn-pdf
January 01, 2022 - Opioid deprescribing toolkit.
January 1, 2022
Health Innovation East, National Health Service. Opioid deprescribing toolkit.
https://psnet.ahrq.gov/issue/opioid-deprescribing-toolkit
Sudden discontinuation of long-term prescription opioid use can lead to adverse outcomes for patients.
Based on research and clinici…
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psnet.ahrq.gov/node/838638/psn-pdf
September 01, 2012 - Directed peer review in surgical pathology.
September 1, 2012
Smith ML, Raab SS. Directed peer review in surgical pathology. Adv Anat Pathol. 2012;19(5):331-337.
doi:10.1097/pap.0b013e31826661b7.
https://psnet.ahrq.gov/issue/directed-peer-review-surgical-pathology
Diagnostic error in pathology can result in delaye…
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psnet.ahrq.gov/node/35022/psn-pdf
June 22, 2009 - The investigation and analysis of critical incidents and
adverse events in healthcare.
June 22, 2009
Woloshynowych M, Rogers S, Taylor-Adams S, et al. The investigation and analysis of critical incidents
and adverse events in healthcare. Health Technol Assess. 2005;9(19):1-143, iii.
https://psnet.ahrq.gov/issue/in…
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psnet.ahrq.gov/node/40764/psn-pdf
December 29, 2014 - Wristbands as aids to reduce misidentification: an
ethnographically guided task analysis.
December 29, 2014
Smith A, Casey K, Wilson J, et al. Wristbands as aids to reduce misidentification: an ethnographically
guided task analysis. Int J Qual Health Care. 2011;23(5):590-9. doi:10.1093/intqhc/mzr045.
https://psnet…
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psnet.ahrq.gov/node/39619/psn-pdf
September 26, 2010 - Devastatingly human: an analysis of registered nurses'
medication error accounts.
September 26, 2010
Treiber LA, Jones JH. Devastatingly human: an analysis of registered nurses' medication error accounts.
Qual Health Res. 2010;20(10):1327-42. doi:10.1177/1049732310372228.
https://psnet.ahrq.gov/issue/devastatingly…
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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…