-
psnet.ahrq.gov/issue/interactions-between-context-health-care-organisation-and-failure-situational-impact-failure
May 17, 2012 - This review includes 49 studies that describe post-failure learning or non-learning behavior within healthcare
-
psnet.ahrq.gov/issue/patient-safety-handbook-second-edition
March 27, 2005 - This revised edition of a comprehensive resource on patient safety includes new chapters discussing such
-
psnet.ahrq.gov/issue/chasing-zero-winning-war-healthcare-harm
May 18, 2012 - This documentary reports on families affected by medical errors; it includes the story of a high-profile
-
psnet.ahrq.gov/issue/improving-diagnosis-medicine-change-package
May 06, 2015 - The publication includes case studies that illustrate implementation challenges and provides infrastructure
-
psnet.ahrq.gov/issue/mortality-and-risk-factors-associated-misdiagnosis-acute-aortic-syndrome-ontario-canada
September 23, 2020 - Misdiagnosis of acute aortic syndrome (AAS), which includes aortic dissection , can result in serious
-
psnet.ahrq.gov/issue/integrative-total-worker-health-framework-keeping-workers-safe-and-healthy-during-covid-19
October 19, 2022 - The recommended approach includes six key characteristics: (1) leadership commitment; (2) policies, programs
-
psnet.ahrq.gov/issue/what-i-wish-id-known-how-experienced-physician-managers-diagnose-treat-and-prevent-disruptive
September 23, 2020 - Disruptive behavior includes behaviors that show disrespect for others and impede safe delivery of patient
-
psnet.ahrq.gov/issue/making-healthcare-safer-iii
March 27, 2019 - It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms
-
psnet.ahrq.gov/issue/customized-triggers-program-childrens-hospitals-experience-improving-trigger-usability
September 01, 2021 - The tool includes criteria from the IHI Global Trigger Tool as well as novel triggers (such as pain
-
psnet.ahrq.gov/issue/clinicians-insights-emergency-department-boarding-explanatory-mixed-methods-study-evaluating
October 23, 2019 - This study includes both qualitative and quantitative methods to understand how ED clinicians view the
-
psnet.ahrq.gov/issue/promises-project
January 30, 2019 - The project also includes a report from physicians, malpractice insurers, and policy experts translating
-
psnet.ahrq.gov/issue/disclosure-apology-and-offer-programs-stakeholders-views-barriers-and-strategies-broad
December 19, 2018 - This model includes full disclosure of adverse events, appropriate investigations, implementation of
-
psnet.ahrq.gov/issue/potential-improved-teamwork-reduce-medical-errors-emergency-department
July 07, 2021 - Discussion includes retrospective analysis of more than 50 incidents suggesting that nearly nine teamwork
-
psnet.ahrq.gov/issue/impact-work-schedules-senior-resident-physicians-patient-and-resident-physician-safety
May 25, 2022 - This study includes residents beyond the first year (i.e., PGY2+).
-
psnet.ahrq.gov/issue/resident-duty-hours-and-resident-and-patient-outcomes-systematic-review-and-meta-analysis
July 14, 2021 - The Accreditation Council for Graduate Medical Education (ACGME) includes work hour restrictions in
-
psnet.ahrq.gov/issue/comprehensive-departmental-care-review-model-requirements-structure-and-flow
July 06, 2022 - The authors outline the care review process, which includes direct care staff feedback; single provider
-
psnet.ahrq.gov/issue/safety-teletriage-nurses-and-physicians-united-states-and-israel-narrative-review-and
April 29, 2020 - This article includes a narrative review and interviews with one American nurse and 15 Israeli pediatric
-
psnet.ahrq.gov/issue/us-poison-control-center-calls-infants-6-months-age-and-younger
November 16, 2022 - Half were coded as "general unintentional," which includes exploratory exposures and other scenarios
-
psnet.ahrq.gov/issue/perspectives-anesthesia-and-perioperative-patient-safety-past-present-and-future
June 19, 2019 - The Safety I framework includes using individual and system failures, analytics, culture, and technology
-
psnet.ahrq.gov/issue/five-years-after-err-human-what-have-we-learned
March 18, 2019 - Discussion includes the evolution of error prevention strategies, the role of interested stakeholders