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psnet.ahrq.gov/node/47145/psn-pdf
July 23, 2018 - The elusive and illusive quest for diagnostic safety
metrics.
July 23, 2018
Schiff G, Ruan EL. The Elusive and Illusive Quest for Diagnostic Safety Metrics. J Gen Intern Med.
2018;33(7):983-985. doi:10.1007/s11606-018-4454-2.
https://psnet.ahrq.gov/issue/elusive-and-illusive-quest-diagnostic-safety-metrics
Measur…
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psnet.ahrq.gov/node/43373/psn-pdf
July 23, 2014 - From harm to hope and purposeful action: what could we
do after Francis?
July 23, 2014
Woodhead T, Lachman P, Mountford J, et al. From harm to hope and purposeful action: what could we do
after Francis? BMJ Qual Saf. 2014;23(8):619-23. doi:10.1136/bmjqs-2013-002581.
https://psnet.ahrq.gov/issue/harm-hope-and-purpo…
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psnet.ahrq.gov/node/41438/psn-pdf
January 03, 2017 - Implementing SBAR across a large multihospital health
system.
January 3, 2017
Compton J, Copeland K, Flanders S, et al. Implementing SBAR across a large multihospital health system.
Jt Comm J Qual Patient Saf. 2012;38(6):261-8.
https://psnet.ahrq.gov/issue/implementing-sbar-across-large-multihospital-health-system…
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psnet.ahrq.gov/node/48111/psn-pdf
July 10, 2019 - Medication Safety in Key Action Areas.
July 10, 2019
Geneva, Switzerland: World Health Organization; 2019.
https://psnet.ahrq.gov/issue/medication-safety-key-action-areas
Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores
key areas of concern that require act…
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psnet.ahrq.gov/node/43898/psn-pdf
February 11, 2015 - Special Section on Patient Safety and Quality in
Healthcare.
February 11, 2015
Andersen HB, Lipczak H, Borch-Johnsen K, eds. Cogn Technol Work. 2015;17:1-155.
https://psnet.ahrq.gov/issue/special-section-patient-safety-and-quality-healthcare
Articles in this special issue explore patient safety from a sociotechnic…
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psnet.ahrq.gov/node/848829/psn-pdf
May 10, 2023 - Lessons from the Covid War: An Investigative Report.
May 10, 2023
Covid Crisis Group. New York: Public Affairs; 2023. ISBN?: ?9781541703803.
https://psnet.ahrq.gov/issue/lessons-covid-war-investigative-report
The transfer of failure experiences to generate learning and improve service is a complicated responsibilit…
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psnet.ahrq.gov/node/842775/psn-pdf
January 18, 2023 - Safer Together Survey: Advancing Patient and Workforce
Safety
January 18, 2023
Cambridge, MA: Institute for Healthcare Improvement: January 2023.
https://psnet.ahrq.gov/issue/safer-together-survey-advancing-patient-and-workforce-safety
The National Steering Committee for Patient Safety (NSC) was formed to engage w…
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psnet.ahrq.gov/node/46026/psn-pdf
May 03, 2017 - Key principles in quality and safety in radiology.
May 3, 2017
Abujudeh H, Kaewlai R, Shaqdan K, et al. Key Principles in Quality and Safety in Radiology. American
Journal of Roentgenology. 2017;208(3). doi:10.2214/ajr.16.16951.
https://psnet.ahrq.gov/issue/key-principles-quality-and-safety-radiology
This review s…
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psnet.ahrq.gov/node/40577/psn-pdf
July 06, 2011 - Reducing potentially fatal errors associated with high
doses of insulin: a successful multifaceted
multidisciplinary prevention strategy.
July 6, 2011
Dooley MJ, Wiseman M, McRae A, et al. Reducing potentially fatal errors associated with high doses of
insulin: a successful multifaceted multidisciplinary preventio…
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psnet.ahrq.gov/node/836871/psn-pdf
April 06, 2022 - The spectrum of harm associated with modern medicine.
April 6, 2022
Schattner A. The spectrum of harm associated with modern medicine. J Gen Intern Med. 2022;37(3):664-
667. doi:10.1007/s11606-021-06997-x.
https://psnet.ahrq.gov/issue/spectrum-harm-associated-modern-medicine
Interest in harm resulting from medical…
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psnet.ahrq.gov/node/46462/psn-pdf
April 11, 2018 - Speaking up: an ethical action exercise.
April 11, 2018
Dwyer J, Faber-Langendoen K. Speaking Up: An Ethical Action Exercise. Acad Med. 2018;93(4):602-605.
doi:10.1097/ACM.0000000000002047.
https://psnet.ahrq.gov/issue/speaking-ethical-action-exercise
Speaking up about concerns is a cornerstone to safety improveme…
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psnet.ahrq.gov/node/72601/psn-pdf
January 01, 2021 - Increasing physician reporting of diagnostic learning
opportunities.
December 23, 2020
Marshall TL, Ipsaro AJ, Le M, et al. Increasing physician reporting of diagnostic learning opportunities.
Pediatrics. 2021;147(1):e20192400. doi:10.1542/peds.2019-2400.
https://psnet.ahrq.gov/issue/increasing-physician-reporting…
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psnet.ahrq.gov/node/45477/psn-pdf
October 05, 2016 - Promoting safety through well-being: an experience in
healthcare.
October 5, 2016
Bruno A, Bracco F. Promoting Safety through Well-Being: An Experience in Healthcare. Front Psychol.
2016;7:1208. doi:10.3389/fpsyg.2016.01208.
https://psnet.ahrq.gov/issue/promoting-safety-through-well-being-experience-healthcare
Th…
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psnet.ahrq.gov/node/73970/psn-pdf
October 21, 2021 - The Good, The Bad, and The Ugly: Patient Experiences
with CRPs.
October 13, 2021
Collaborative for Accountability and Improvement. October 21, 2021.
https://psnet.ahrq.gov/issue/good-bad-and-ugly-patient-experiences-crps
Communication-and-resolution program (CRP) initiatives are a valuable strategy for impro…
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psnet.ahrq.gov/node/44846/psn-pdf
August 31, 2016 - Making health care safer: protect patients from antibiotic
resistance.
August 31, 2016
CDC; Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/making-health-care-safer-protect-patients-antibiotic-resistance
Health care–associated infections (HAI) are a worldwide patient safety problem. This a…
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psnet.ahrq.gov/node/45386/psn-pdf
November 23, 2016 - Balancing doctor egos and errors.
November 23, 2016
Sweeney JF. Medical Economics. November 10, 2016.
https://psnet.ahrq.gov/issue/balancing-doctor-egos-and-errors
Disclosure and candor with patients after a medical error has gained support from organizations, clinicians,
and patients. This magazine article discus…
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psnet.ahrq.gov/node/47353/psn-pdf
October 03, 2018 - The need for cognition and the curse of cognition.
October 3, 2018
Croskerry P. The need for cognition and the curse of cognition. Diagnosis (Berl). 2018;5(3):91-94.
doi:10.1515/dx-2018-0072.
https://psnet.ahrq.gov/issue/need-cognition-and-curse-cognition
Cognitive bias is increasingly receiving recognition as a b…
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psnet.ahrq.gov/node/73896/psn-pdf
September 29, 2021 - Policies to promote shared responsibility for safer
electronic health records.
September 29, 2021
Sittig DF, Singh H. Policies to promote shared responsibility for safer electronic health records. JAMA.
2021;326(15):1477-1478. doi:10.1001/jama.2021.13945.
https://psnet.ahrq.gov/issue/policies-promote-shared-respon…
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psnet.ahrq.gov/node/73543/psn-pdf
July 28, 2021 - AMC PSO Resource Center.
July 28, 2021
Academic Medical Center Patient Safety Organization.
https://psnet.ahrq.gov/issue/amc-pso-resource-center
Patient Safety organizations (PSO) are in a unique position to educate their members and the larger
community on patient safety challenges. This PSO resource collection i…
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psnet.ahrq.gov/node/846455/psn-pdf
March 22, 2023 - Diagnostic Centers of Excellence (X01 Clinical Trial Not
Allowed).
March 22, 2023
PAR-23-120. Bethesda, MD: National Institutes of Health; March 7, 2023
https://psnet.ahrq.gov/issue/diagnostic-centers-excellence-x01-clinical-trial-not-allowed
Approaching diagnosis as a team activity is seen as a key approach to di…