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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73215/psn-pdf
    May 05, 2021 - To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. May 5, 2021 Isherwood P, Waterson P. To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. J Patient Saf Risk Manag. 2021;26(2):64-73. doi:10.1177/2516043521990…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34690/psn-pdf
    February 10, 2011 - Systems analysis of adverse drug events. February 10, 2011 Leape L, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274(1):35-43. https://psnet.ahrq.gov/issue/systems-analysis-adverse-drug-events The authors report a "systems analysis" of the adverse drug…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42249/psn-pdf
    May 08, 2013 - Is detection of adverse events affected by record review methodology? An evaluation of the "Harvard Medical Practice Study" method and the "Global Trigger Tool." May 8, 2013 Unbeck M, Schildmeijer K, Henriksson P, et al. Is detection of adverse events affected by record review methodology? an evaluation of the "Ha…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44876/psn-pdf
    February 10, 2016 - The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures and Lack of Mindfulness. February 10, 2016 Anderson-Fletcher E, Vera D, Abbott J. Houston, TX: Hobbs Center for Public Policy, University of Houston; 2015. https://psnet.ahrq.gov/issue/texas-health-presbyterian-h…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/856588/psn-pdf
    November 29, 2023 - It depends who you ask: divergences in staff and external stakeholder narratives about the causes of a healthcare failure. November 29, 2023 Hald EJ, Gillespie A, Reader TW. It depends who you ask: divergences in staff and external stakeholder narratives about the causes of a healthcare failure. J Contingencies Cr…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/856590/psn-pdf
    November 29, 2023 - Team experiences of the root cause analysis process after a sentinel event: a qualitative case study. November 29, 2023 Liepelt S, Sundal H, Kirchhoff R. Team experiences of the root cause analysis process after a sentinel event: a qualitative case study. BMC Health Serv Res. 2023;23(1):1224. doi:10.1186/s12913-023…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73169/psn-pdf
    April 21, 2021 - Application of emergency preparedness principles to a pharmacy department’s approach to a “black swan” event: the COVID-19 pandemic. April 21, 2021 Waldron KM, Schenkat DH, Rao KV, et al. Application of emergency preparedness principles to a pharmacy department’s approach to a “black swan” event: the COVID-19 pand…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866811/psn-pdf
    September 25, 2024 - Association between potentially inappropriate medications prescription and health-related quality of life among US older adults. September 25, 2024 Clark CM, Guan J, Patel AR, et al. Association between potentially inappropriate medications prescription and health?related quality of life among US older adults. J A…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849325/psn-pdf
    January 01, 2024 - Medication safety event reporting: factors that contribute to safety events during times of organizational stress. May 24, 2023 Cohen TN, Berdahl CT, Coleman BL, et al. Medication safety event reporting: factors that contribute to safety events during times of organizational stress. J Nurs Care Qual. 2024;39(1):51-…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45487/psn-pdf
    July 21, 2020 - Annotated bibliography: an update to: "Understanding ambulatory care practices in the context of patient safety and quality improvement." July 21, 2020 Kumar PR, Nash DB. Annotated Bibliography: An Update to “Understanding Ambulatory Care Practices in the Context of Patient Safety and Quality Improvement”. Am J Me…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60743/psn-pdf
    July 29, 2020 - The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies. July 29, 2020 Furrow BR. The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies. Am J Law Med. 2020;46(2-3):219-235…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44914/psn-pdf
    February 15, 2017 - Safer prescribing—a trial of education, informatics, and financial incentives. February 15, 2017 Dreischulte T, Donnan P, Grant A, et al. Safer Prescribing--A Trial of Education, Informatics, and Financial Incentives. N Engl J Med. 2016;374(11):1053-64. doi:10.1056/NEJMsa1508955. https://psnet.ahrq.gov/issue/safer…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34103/psn-pdf
    February 24, 2011 - Measuring errors and adverse events in health care. February 24, 2011 Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med. 2003;18(1). doi:10.1046/j.1525-1497.2003.20147.x. https://psnet.ahrq.gov/issue/measuring-errors-and-adverse-events-health-care This article discusses t…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36696/psn-pdf
    July 10, 2008 - The impact of video games on training surgeons in the 21st century.   July 10, 2008 Rosser JC, Lynch PJ, Cuddihy L, et al. The impact of video games on training surgeons in the 21st century. Arch Surg. 2007;142(2):181-6; discusssion 186. https://psnet.ahrq.gov/issue/impact-video-games-training-surgeons-21st-centur…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836919/psn-pdf
    April 13, 2022 - Psychological intervention to improve communication and patient safety in obstetrics: examination of the health action process approach. April 13, 2022 Derksen C, Kötting L, Keller FM, et al. Psychological intervention to improve communication and patient safety in obstetrics: examination of the health action proc…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35516/psn-pdf
    February 03, 2011 - Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. February 3, 2011 Belda J, Aguilera L, de la Asunción JG, et al. Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA. 2005;294(16):2035-42. https://p…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60293/psn-pdf
    May 06, 2020 - Blueprint for restructuring a department of surgery in concert with the health care system during a pandemic: the University of Wisconsin Experience. May 6, 2020 Zarzaur BL, Stahl CC, Greenberg JA, et al. Blueprint for restructuring a department of surgery in concert with the health care system during a pandemic: …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47980/psn-pdf
    May 01, 2019 - Intensive care medicine in 2050: preventing harm. May 1, 2019 Beet C, Benoit D, Bion J. Intensive care medicine in 2050: preventing harm. Intensive Care Med. 2019;45(4):505-507. doi:10.1007/s00134-018-5353-z. https://psnet.ahrq.gov/issue/intensive-care-medicine-2050-preventing-harm This commentary discusses curren…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74705/psn-pdf
    January 26, 2022 - 20 years after To Err Is Human: a bibliometric analysis of ‘the IOM report’s’ impact on research on patient safety. January 26, 2022 St.Pierre M, Grawe P, Bergström J, et al. 20 years after To Err Is Human: a bibliometric analysis of ‘the IOM report’s’ impact on research on patient safety. Safety Sci. 2021;147:1055…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73632/psn-pdf
    January 01, 2022 - I-PSI: short- and long-term efficacy of a comprehensive initiative to promote patient safety event reporting by trainees. August 25, 2021 Prabhu V, Mikhly M, Chung R, et al. I-PSI: short- and long-term efficacy of a comprehensive initiative to promote patient safety event reporting by trainees. Am J Med Qual. 2022…
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