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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45590/psn-pdfAugust 02, 2017 - Improving Diagnostic Accuracy Project 2016–2017. August 2, 2017 Washington, DC: National Quality Forum; October 2016. https://psnet.ahrq.gov/issue/improving-diagnostic-accuracy-project-2016-2017 The Improving Diagnosis in Health Care report provided recommendations to help achieve safe, reliable diagnosis. This we… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36841/psn-pdfDecember 31, 2014 - Using medical malpractice closed claims data to reduce surgical risk and improve patient safety. December 31, 2014 Manuel BM, Greenwald LM. Using medical malpractice closed claims data to reduce surgical risk and improve patient safety. Bull Am Coll Surg. 2007;92(3):27-30. https://psnet.ahrq.gov/issue/using-medica… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43212/psn-pdfSeptember 27, 2017 - Errors of omission: missed nursing care. September 27, 2017 Kalisch BJ, Xie B. Errors of Omission: Missed Nursing Care. West J Nurs Res. 2014;36(7):875-890. doi:10.1177/0193945914531859. https://psnet.ahrq.gov/issue/errors-omission-missed-nursing-care Nurse staffing ratios have been linked to patient safety issues… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43795/psn-pdfDecember 17, 2014 - Systematic Systems Analysis: A Practical Approach to Patient Safety Reviews. December 17, 2014 Duchscherer C, Davies JM. Calgary, Alberta, Canada: Health Quality Council of Alberta; 2012. https://psnet.ahrq.gov/issue/systematic-systems-analysis-practical-approach-patient-safety-reviews Drawing from human factors a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/854639/psn-pdfOctober 18, 2023 - Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive. October 18, 2023 Edmondson A. Atria Books, New York, 2023. ISBN: 9781982195069. https://psnet.ahrq.gov/issue/right-kind-wrong-why-learning-fail-can-teach-us-thrive Despite the harm that failure can cause, its value as a learning opportunity, if exam… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46767/psn-pdfJanuary 17, 2018 - What this computer needs is a physician: humanism and artificial intelligence. January 17, 2018 Verghese A, Shah NH, Harrington RA. What This Computer Needs Is a Physician: Humanism and Artificial Intelligence. JAMA. 2018;319(1):19-20. doi:10.1001/jama.2017.19198. https://psnet.ahrq.gov/issue/what-computer-needs-p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45750/psn-pdfFebruary 01, 2017 - Cognitive biases associated with medical decisions: a systematic review. February 1, 2017 Saposnik G, Redelmeier DA, Ruff CC, et al. Cognitive biases associated with medical decisions: a systematic review. BMC Med Inform Decis Mak. 2016;16(1):138. https://psnet.ahrq.gov/issue/cognitive-biases-associated-medical-de… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43916/psn-pdfNovember 30, 2016 - Safer Clinical Systems: Evaluation Findings. November 30, 2016 Dixon-Woods M, Martin G, Tarrant C, et al. London, UK: Health Foundation; December 2014. https://psnet.ahrq.gov/issue/safer-clinical-systems-evaluation-findings This report discusses the results of a United Kingdom initiative exploring how safety strate… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35415/psn-pdfDecember 21, 2008 - Acting Locally: Working in Clinical Microsystems CD- ROM. December 21, 2008 Oakbrook Terrance, IL: Joint Commission Resources; 2005. ISBN 9780866889865. https://psnet.ahrq.gov/issue/acting-locally-working-clinical-microsystems-cd-rom This resource represents a collection of special articles published in the Joint … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45801/psn-pdfAugust 03, 2017 - Overcoming diagnostic errors in medical practice. August 3, 2017 Bordini BJ, Stephany A, Kliegman RM. Overcoming Diagnostic Errors in Medical Practice. J Pediatr. 2017;185. doi:10.1016/j.jpeds.2017.02.065. https://psnet.ahrq.gov/issue/overcoming-diagnostic-errors-medical-practice This commentary describes a progra… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43654/psn-pdfApril 02, 2015 - Nursing bedside clinical handover—an integrated review of issues and tools. April 2, 2015 Anderson J, Malone L, Shanahan K, et al. Nursing bedside clinical handover - an integrated review of issues and tools. J Clin Nurs. 2015;24(5-6):662-671. doi:10.1111/jocn.12706. https://psnet.ahrq.gov/issue/nursing-bedside-cl… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44126/psn-pdfMay 13, 2015 - SAFER Electronic Health Records: Safety Assurance Factors for EHR Resilience. May 13, 2015 Sittig DF, Singh H, eds. Waretown, NJ: Apple Academic Press; 2015. ISBN: 9781771881173. https://psnet.ahrq.gov/issue/safer-electronic-health-records-safety-assurance-factors-ehr-resilience Implementation of electronic health… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36207/psn-pdfOctober 13, 2010 - Using failure mode and effects analysis to plan implementation of smart i.v. pump technology. October 13, 2010 Wetterneck TB, Skibinski K, Roberts TL, et al. Using failure mode and effects analysis to plan implementation of smart i.v. pump technology. Am J Health Syst Pharm. 2006;63(16):1528-38. https://psnet.ahrq… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45885/psn-pdfMay 03, 2017 - E-collection: Safety and Error Prevention in Health. May 3, 2017 https://psnet.ahrq.gov/issue/e-collection-safety-and-error-prevention-health The increasing implementation of health information technology has introduced both benefits and challenges to patient safety. Articles in this series explore the impacts of t… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43335/psn-pdfJuly 09, 2014 - Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. July 9, 2014 Tjia I, Rampersad S, Varughese AM, et al. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Anesth Analg. 2014;119(1):122-136. doi:10.1213/ANE.0000000000000266. https://psnet.ahrq.gov/is… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39295/psn-pdfJanuary 03, 2017 - The Veterans Affairs shift change physician-to-physician handoff project. January 3, 2017 Anderson J, Shroff D, Curtis A, et al. The Veterans Affairs shift change physician-to-physician handoff project. Jt Comm J Qual Patient Saf. 2010;36(2):62-71. https://psnet.ahrq.gov/issue/veterans-affairs-shift-change-physici… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836871/psn-pdfApril 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… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46136/psn-pdfSeptember 27, 2017 - Medication errors in injured patients. September 27, 2017 Dolejs SC, Janowak CF, Zarzaur BL. Medication Errors in Injured Patients. Am Surg. 2017;83(7):780-785. https://psnet.ahrq.gov/issue/medication-errors-injured-patients Despite the widespread adoption of health information technology, medication errors remain … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36223/psn-pdfMay 27, 2011 - Prescribers' responses to alerts during medication ordering in the long term care setting. May 27, 2011 Judge J, Field T, DeFlorio M, et al. Prescribers' responses to alerts during medication ordering in the long term care setting. J Am Med Inform Assoc. 2006;13(4):385-90. https://psnet.ahrq.gov/issue/prescribers-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837982/psn-pdfAugust 31, 2022 - Patient Safety Incident Response Framework. August 31, 2022 London, England: NHS England; August 2022. https://psnet.ahrq.gov/issue/patient-safety-incident-response-framework Effective response to medical error requires a comprehensive systemic and process-focused incident examination approach to ensure organizati…
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