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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…
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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…
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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…
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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
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Organization:
Organization
American Academy of Ophthalmology
Even…
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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…
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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…
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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.
…
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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…
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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…
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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
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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
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psnet.ahrq.gov/web-mm/pocket-syringe-swap
July 01, 2006 - Related Resources
WebM&M Cases
Medication Mix-Up Leads
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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
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psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
January 07, 2015 - May 26, 2021
WebM&M Cases
Lapse in Antibiotics Leads
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psnet.ahrq.gov/web-mm/dressed-failure
September 01, 2011 - May 31, 2023
WebM&M Cases
Lapse in Antibiotics Leads
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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
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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
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psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
May 01, 2017 - September 7, 2011
WebM&M Cases
Lapse in Antibiotics Leads
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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
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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