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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34782/psn-pdf
    November 01, 2016 - When systems fail. November 1, 2016 Roberts KH, Bea RG. When systems fail. Organ Dyn. 2002;29(3):179-191. doi:10.1016/s0090- 2616(01)00025-0. https://psnet.ahrq.gov/issue/when-systems-fail This review provides a detailed account of managerial causes of failure and managerial failure prevention strategies. The aut…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838184/psn-pdf
    September 28, 2022 - The hidden risk of wheelchair use. September 28, 2022 Quesenberry M. The hidden risk of wheelchair use. Patient Safety. 2022;4(3):6-9. doi:10.33940/alert/2022.9.1. https://psnet.ahrq.gov/issue/hidden-risk-wheelchair-use Medical devices intended to improve patient safety can unintentionally lead to patient harm. Th…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60928/psn-pdf
    September 16, 2020 - The risks of the prescribing cascade. September 16, 2020 Brody JE. The risks of the prescribing cascade. New York Times. 2020. https://psnet.ahrq.gov/issue/risks-prescribing-cascade Inappropriate care activities can cascade to significantly impact patient safety. This article shares how medication side effects can…
  4. psnet.ahrq.gov/training-catalog/medical-mistakes-and-what-doctors-can-learn-pilots
    July 21, 2025 - Medical Mistakes and What Doctors Can Learn From Pilots Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization American Academy of Ophthalmology Even…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44481/psn-pdf
    September 09, 2015 - When doctors get it wrong: misdiagnoses are getting a closer look. September 9, 2015 Olsen J. Star Tribune. August 30, 2015. https://psnet.ahrq.gov/issue/when-doctors-get-it-wrong-misdiagnoses-are-getting-closer-look Diagnostic error is garnering increased attention as a patient safety problem. This news article r…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39683/psn-pdf
    June 08, 2011 - Surgical team training: promoting high reliability with nontechnical skills. June 8, 2011 Paige JT. Surgical team training: promoting high reliability with nontechnical skills. Surg Clin North Am. 2010;90(3):569-81. doi:10.1016/j.suc.2010.02.007. https://psnet.ahrq.gov/issue/surgical-team-training-promoting-high-r…
  7. psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
    September 24, 2024 - In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement Carole Stockmeier, Sarah Mossburg, Lee Merton | September 24, 2024  Also Read the Essay View more articles from the same authors. …
  8. psnet.ahrq.gov/perspective/conversation-cheryl-jones-about-addressing-workplace-violence-and-creating-safer
    October 31, 2023 - In Conversation with... Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace Cheryl B. Jones, PhD, RN, FAAN | October 31, 2023  Also Read the Essay View more articles from the same authors. Citation Text: Jones CB. In Conversation with…
  9. psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
    October 31, 2023 - Addressing Workplace Violence and Creating a Safer Workplace Cheryl B. Jones, PhD, RN, FAAN; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | October 31, 2023  Also Read the Conversation View more articles from the same authors. Citation Text: Jones CB, Sousane Z…
  10. psnet.ahrq.gov/web-mm/or
    August 22, 2013 - This leads to greater challenges in catching the mistake, and the lack of predictability makes it harder
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33703/psn-pdf
    November 01, 2010 - This type of ad hoc reporting frequently leads to underestimation and underdetection of safety events
  12. psnet.ahrq.gov/web-mm/pocket-syringe-swap
    July 01, 2006 - Related Resources WebM&M Cases Medication Mix-Up Leads
  13. psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
    October 01, 2017 - Cases Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads
  14. psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
    January 07, 2015 - May 26, 2021 WebM&M Cases Lapse in Antibiotics Leads
  15. psnet.ahrq.gov/web-mm/dressed-failure
    September 01, 2011 - May 31, 2023 WebM&M Cases Lapse in Antibiotics Leads
  16. psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
    October 02, 2019 - Cases Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads
  17. psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
    July 28, 2021 - Related Resources WebM&M Cases Saline Flush Leads
  18. psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
    May 01, 2017 - September 7, 2011 WebM&M Cases Lapse in Antibiotics Leads
  19. psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
    January 07, 2015 - Having clinicians thrust into an emergency "hurry-up" situation should be a red flag that leads to recognition
  20. psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
    February 12, 2020 - A stat electrocardiogram revealed ST elevation in the inferior leads, diagnostic of a myocardial infarction

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