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psnet.ahrq.gov/issue/disclosure-coaching-ask-tell-ask-model-support-clinicians-disclosure-conversations
December 18, 2014 - Commentary
Disclosure coaching: an ask-tell-ask model to support clinicians in disclosure conversations.
Citation Text:
Shapiro J, Robins L, Galowitz P, et al. Disclosure Coaching: An Ask-Tell-Ask Model to Support Clinicians in Disclosure Conversations. J Patient Saf. 2021;17(8):e1364-e1…
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psnet.ahrq.gov/issue/how-develop-second-victim-support-program-toolkit-health-care-organizations
April 03, 2019 - Commentary
How to develop a second victim support program: a toolkit for health care organizations.
Citation Text:
Pratt SD, Kenney L, Scott SD, et al. How to develop a second victim support program: a toolkit for health care organizations. Jt Comm J Qual Patient Saf. 2012;38(5):235-40, …
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psnet.ahrq.gov/issue/cognitive-errors-and-logistical-breakdowns-contributing-missed-and-delayed-diagnoses-breast
March 02, 2011 - Study
Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims.
Citation Text:
Poon EG, Kachalia A, Puopolo AL, et al. Cognitive errors and logistical breakdowns contributin…
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psnet.ahrq.gov/issue/using-advanced-practice-nursing-model-rapid-response-team
August 18, 2021 - Commentary
Using an advanced practice nursing model for a rapid response team.
Citation Text:
Benson L, Mitchell C, Link M, et al. Using an advanced practice nursing model for a rapid response team. Jt Comm J Qual Patient Saf. 2008;34(12):743-7.
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psnet.ahrq.gov/issue/second-victim-casualties-and-how-physician-leaders-can-help
August 28, 2024 - Newspaper/Magazine Article
"Second victim" casualties and how physician leaders can help.
Citation Text:
MacLeod L. "Second victim" casualties and how physician leaders can help. Physician Exect. 2014;40(1):8-12.
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psnet.ahrq.gov/issue/shedding-light-dark-side-doctor-patient-interactions-verbal-and-nonverbal-messages-physicians
June 14, 2017 - Study
Shedding light on the dark side of doctor–patient interactions: verbal and nonverbal messages physicians communicate during error disclosures.
Citation Text:
Hannawa AF. Shedding light on the dark side of doctor-patient interactions: verbal and nonverbal messages physicians commu…
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psnet.ahrq.gov/issue/reducing-adverse-events-blood-transfusion
June 25, 2008 - Commentary
Reducing adverse events in blood transfusion.
Citation Text:
Stainsby D, Russell J, Cohen H, et al. Reducing adverse events in blood transfusion. Br J Haematol. 2005;131(1). doi:10.1111/j.1365-2141.2005.05702.x.
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psnet.ahrq.gov/issue/safety-attitudes-questionnaire-tool-benchmarking-safety-culture-nicu
March 02, 2012 - Study
The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU.
Citation Text:
Profit J, Etchegaray J, Petersen L, et al. The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU. Arch Dis Child Fetal Neonatal Ed. 2012;97(…
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psnet.ahrq.gov/issue/medical-harm-historical-conceptual-and-ethical-dimensions-iatrogenic-illness
May 13, 2020 - Book/Report
Classic
Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness.
Citation Text:
Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness. Sharpe VA, Faden AI. Cambridge NY; Cambridge University…
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psnet.ahrq.gov/issue/it-matters-what-i-think-not-what-you-say-scientific-evidence-medical-error-disclosure
September 29, 2017 - Study
"It matters what I think, not what you say": scientific evidence for a medical error disclosure competence (MEDC) model.
Citation Text:
Hannawa AF, Frankel RM. "It Matters What I Think, Not What You Say": Scientific Evidence for a Medical Error Disclosure Competence (MEDC) Model. J…
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psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
February 01, 2012 - In one study that examined closed malpractice claims involving trainees, lack of resident supervision … Medical errors involving trainees: a study of closed malpractice claims from 5 insurers.
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - On POD 7, the patient developed persistent myoclonus involving his hands and arms; his gabapentin dose … neurological toxicities are usually reversible with dialysis or renal replacement therapy. 8 In this case involving
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psnet.ahrq.gov/node/60744/psn-pdf
July 29, 2020 - stratification or heart
failure assessment are well-described in the literature, curbside consultations involving … frequency of diagnostic errors in outpatient care: estimations
from three large observational studies involving
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - Role of Direct-acting Oral Anticoagulants versus Other Anticoagulants
Thrombosis involving either … therapy can occur due to patient non-adherence, insurance-related problems (as in this case), procedures involving
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psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
February 01, 2012 - In one study that examined closed malpractice claims involving trainees, lack of resident supervision … Medical errors involving trainees: a study of closed malpractice claims from 5 insurers.
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - An HFE approach for such a problem would be to redesign the system while involving the users throughout
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psnet.ahrq.gov/node/43109/psn-pdf
December 10, 2014 - relates one hospital's experience with engaging physician leadership in quality
improvement efforts by involving
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psnet.ahrq.gov/node/44559/psn-pdf
April 15, 2016 - Researchers determined that diagnostic errors occurred in 35 of 100 reviewed cases, with the
majority involving
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psnet.ahrq.gov/node/46501/psn-pdf
March 20, 2018 - blind-obedience-and-unnecessary-workup-hypoglycemia-teachable-moment
This commentary relates an incident involving
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psnet.ahrq.gov/node/46651/psn-pdf
January 17, 2018 - project to incorporate patient safety and quality improvement content into a larger educational effort
involving