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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836927/psn-pdfApril 13, 2022 - The problem with making Safety-II work in healthcare. April 13, 2022 Verhagen MJ, de Vos MS, Sujan M, et al. The problem with making Safety-II work in healthcare. BMJ Qual Saf. 2022;31(5):402-408. doi:10.1136/bmjqs-2021-014396. https://psnet.ahrq.gov/issue/problem-making-safety-ii-work-healthcare The Safety-II fra… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37269/psn-pdfNovember 30, 2016 - ACOG Committee Opinion #681: disclosure and discussion of adverse events. November 30, 2016 Improvement C on PS and Q. Committee Opinion No. 681: Disclosure and Discussion of Adverse Events. Obstet Gynecol. 2016;128(6):e257-e261. https://psnet.ahrq.gov/issue/acog-committee-opinion-681-disclosure-and-discussion-adv… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/865820/psn-pdfMay 08, 2024 - Breaking the silence on medical mistakes. May 8, 2024 Scott M. The Pulse. New York Public Radio; April 26, 2024. https://psnet.ahrq.gov/issue/breaking-silence-medical-mistakes Individuals involved in medical errors need time and support to process the incident and its consequences. This moderated podcast examines … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72831/psn-pdfMarch 10, 2021 - Enhancing a culture of safety through disclosure of adverse events. March 10, 2021 Cornelissen C, Call RC, Harbell MW, et al. APSF Newsletter. February 202136(1);25-27 https://psnet.ahrq.gov/issue/enhancing-culture-safety-through-disclosure-adverse-events Error disclosure is supported by a robust safety … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37038/psn-pdfSeptember 16, 2011 - Does simulation improve patient safety?: self-efficacy, competence, operational performance, and patient safety. September 16, 2011 Nishisaki A, Keren R, Nadkarni V. Does simulation improve patient safety? Self-efficacy, competence, operational performance, and patient safety. Anesthesiol Clin. 2007;25(2):225-36. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/74119/psn-pdfNovember 24, 2021 - When we're all responsible for a patient's death, no one is. November 24, 2021 Prasad V, Medpage Today. November 16, 2021. https://psnet.ahrq.gov/issue/when-were-all-responsible-patients-death-no-one The issue of system versus individual accountability can challenge the orientation of safety improvement effo… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35595/psn-pdfJanuary 04, 2009 - Patient Safety: Achieving a New Standard of Care. January 4, 2009 Institute of Medicine (US) Committee on Data Standards for Patient Safety, Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Washington (DC): National Academies Press (US); 2004. https://psnet.ahrq.gov/issue/patient-safety-achieving-new-standa… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60998/psn-pdfOctober 07, 2020 - The slow, troubling death of the autopsy. October 7, 2020 Ashworth S. Elemental. September 22, 2020. https://psnet.ahrq.gov/issue/slow-troubling-death-autopsy The rate of autopsies – the “gold standard” of death investigation – are decreasing worldwide. This commentary highlights the lost opportunities for ho… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41931/psn-pdfDecember 19, 2012 - Preventing wrong-site surgery in Minnesota: a 5-year journey. December 19, 2012 Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34. https://psnet.ahrq.gov/issue/preventing-wrong-site-surgery-minnesota-5-year-journey Discussing a 5-year effort to report, analyze, and red… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35962/psn-pdfApril 18, 2011 - Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting. April 18, 2011 Smith AF, Goodwin D, Mort M, et al. Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting. Br J Anaesth. 2006;96(6):715-21. https://psnet.ahrq.gov/issue/adve… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44108/psn-pdfNovember 06, 2015 - Service members are left in dark on health errors. November 6, 2015 LaFraniere S. New York Times. April 19, 2015. https://psnet.ahrq.gov/issue/service-members-are-left-dark-health-errors Reporting on a case involving an overlooked test result that contributed to the death of a patient in the military medical syste… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/74849/psn-pdfFebruary 16, 2022 - Healthcare Systems Ergonomics and Patient Safety Triennial Conference. February 16, 2022 Delft University of Technology. Faculty Industrial Design Engineering. Delft, The Netherlands, November 2- 4, 2022 https://psnet.ahrq.gov/issue/healthcare-systems-ergonomics-and-patient-safety-triennial-conference Learning fr… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35946/psn-pdfJuly 26, 2010 - A review of educational philosophies as applied to radiation safety training at medical institutions. July 26, 2010 Dauer LT, St Germain J. A review of educational philosophies as applied to radiation safety training at medical institutions. Health Phys. 2006;90(5 Suppl):S67-72. https://psnet.ahrq.gov/issue/review… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37638/psn-pdfMay 24, 2015 - Work hours regulations for house staff in psychiatry: bad or good for residency training? May 24, 2015 Rasminsky S, Lomonaco A, Auchincloss E. Work Hours Regulations for House Staff in Psychiatry: Bad or Good for Residency Training? Academic Psychiatry. 2008;32(1). doi:10.1176/appi.ap.32.1.54. https://psnet.ahrq.g… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60042/psn-pdfMarch 11, 2020 - At Walgreens, complaints of medication errors go missing. March 11, 2020 Gabler E. New York Times. February 23, 2020. https://psnet.ahrq.gov/issue/walgreens-complaints-medication-errors-go-missing Response to reported safety concerns is a primary indicator of an organizational commitment to reducing and lear… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44760/psn-pdfJuly 10, 2024 - Collaborative for Accountability and Improvement. July 10, 2024 University of Washington. https://psnet.ahrq.gov/issue/collaborative-accountability-and-improvement Communication-and-resolution programs (CRPs) are a promising strategy to improve respectful and effective discussions with patients and families after … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42957/psn-pdfMarch 05, 2014 - Massachusetts Alliance for Communication and Resolution Following Medical Injury. March 5, 2014 Betsy Lehman Center for Patient Safety. https://psnet.ahrq.gov/issue/massachusetts-alliance-communication-and-resolution-following-medical-injury Communication-and-response programs emphasize early disclosure of adverse… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38198/psn-pdfMay 05, 2018 - ISMP's second QuarterWatch report shows sharp increase in reports of serious adverse drug events. May 5, 2018 ISMP Medication Safety Alert! Acute Care Edition. October 23, 2008;13:1-3. https://psnet.ahrq.gov/issue/ismps-second-quarterwatch-report-shows-sharp-increase-reports-serious- adverse-drug-events This news… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42586/psn-pdfSeptember 11, 2013 - A hazard of impatient medicine. September 11, 2013 Gunderman R, Lynch J, Harrell H. The Atlantic. September 3, 2013. https://psnet.ahrq.gov/issue/hazard-impatient-medicine This magazine article reports on the unique tension between efficiency mandates and patient-centered care through the example of a cancer patie… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45478/psn-pdfOctober 26, 2016 - Core principles of quality improvement and patient safety. October 26, 2016 Bartman T, McClead RE. Core Principles of Quality Improvement and Patient Safety. Pediatr Rev. 2016;37(10):407-417. https://psnet.ahrq.gov/issue/core-principles-quality-improvement-and-patient-safety This review discusses key patient safet…
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