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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/861291/psn-pdfJanuary 24, 2024 - COVID-19 and patient safety- lessons from 2 efforts to keep people safe. January 24, 2024 Wachter RM. COVID-19 and patient safety- lessons from 2 efforts to keep people safe. JAMA Intern Med. 2024;184(2):127-128. doi:10.1001/jamainternmed.2023.7527. https://psnet.ahrq.gov/issue/covid-19-and-patient-safety-lessons-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40623/psn-pdfJuly 20, 2011 - Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap. July 20, 2011 Nicolini D, Waring J, Mengis J. Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap. Soc Sci Med. 2011;73(2):217-25. doi:10.1016/j.socscime… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/860391/psn-pdfJanuary 10, 2024 - Neonatal near-miss audits: a systematic review and a call to action. January 10, 2024 Medeiros PB, Bailey C, Pollock D, et al. Neonatal near-miss audits: a systematic review and a call to action. BMC Pediatr. 2023;23(1):573. doi:10.1186/s12887-023-04383-6. https://psnet.ahrq.gov/issue/neonatal-near-miss-audits-sys… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34861/psn-pdfNovember 11, 2015 - When things go wrong: how health care organizations deal with major failures. November 11, 2015 Walshe K, Shortell SM. When things go wrong: how health care organizations deal with major failures. Health Aff (Millwood). 2004;23(3):103-11. https://psnet.ahrq.gov/issue/when-things-go-wrong-how-health-care-organizati… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866324/psn-pdfJuly 17, 2024 - Total systems safety supports practitioners in partnering with families to protect patients. July 17, 2024 ISMP Medication Safety Alert! Acute Care. 2024;29(13):1-4. https://psnet.ahrq.gov/issue/total-systems-safety-supports-practitioners-partnering-families-protect-patients Patient and family concerns can provide… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46563/psn-pdfFebruary 07, 2018 - Near-miss medication errors provide a wake-up call. February 7, 2018 Claffey C. Near-miss medication errors provide a wake-up call. Nursing (Brux). 2018;48(1):53-55. doi:10.1097/01.NURSE.0000527615.45031.9e. https://psnet.ahrq.gov/issue/near-miss-medication-errors-provide-wake-call Case studies of adverse events a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43971/psn-pdfApril 25, 2016 - Why empathy may be the best risk management strategy. April 25, 2016 Hertz BT. Why empathy may be the best risk management strategy. Medical economics. 2015;92(3):40-4. https://psnet.ahrq.gov/issue/why-empathy-may-be-best-risk-management-strategy Communication and response strategies have been shown to improve how … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46813/psn-pdfMarch 14, 2018 - Our other prescription drug problem. March 14, 2018 Lembke A, Papac J, Humphreys K. Our Other Prescription Drug Problem. N Engl J Med. 2018;378(8):693- 695. doi:10.1056/NEJMp1715050. https://psnet.ahrq.gov/issue/our-other-prescription-drug-problem Unintended consequences can emerge when targeted strategies divert … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/852448/psn-pdfJanuary 01, 2024 - A realist synthesis of interprofessional patient safety activities and healthcare student attitudes towards patient safety. August 16, 2023 Cleary E, Bloomfield J, Frotjold A, et al. A realist synthesis of interprofessional patient safety activities and healthcare student attitudes towards patient safety. J Interp… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44797/psn-pdfMarch 15, 2016 - Incident and error reporting systems in intensive care: a systematic review of the literature. March 15, 2016 Brunsveld-Reinders AH, Arbous S, De Vos R, et al. Incident and error reporting systems in intensive care: a systematic review of the literature. Int J Qual Health Care. 2016;28(1):2-13. doi:10.1093/intqhc/m… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866243/psn-pdfJuly 10, 2024 - Building a resilient patient safety culture: a large healthcare organization's approach to systematically reviewing serious harm events. July 10, 2024 Harvey B, Dhalla IA, O'Neill C, et al. Building a resilient patient safety culture: a large healthcare organization's approach to systematically reviewing serious h… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73468/psn-pdfJuly 07, 2021 - The implementation of communication didactics for OB/GYN residents on the disclosure of adverse perioperative events. July 7, 2021 Chung EH, Truong T, Jooste KR, et al. The implementation of communication didactics for OB/GYN residents on the disclosure of adverse perioperative events. J Surg Educ. 2021;78(3):942-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866281/psn-pdfJuly 10, 2024 - Updating Eindhoven: clarifying the features of a patient safety near miss. July 10, 2024 Woodier N, Burnett C, Sampson P, et al. Updating Eindhoven: clarifying the features of a patient safety near miss. J Patient Saf Risk Manag. 2024;29(4):195-201. doi:10.1177/25160435241247096. https://psnet.ahrq.gov/issue/updat… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47931/psn-pdfJanuary 01, 2020 - Managing risk in hazardous conditions: improvisation is not enough. July 24, 2019 Amalberti R, Vincent CA. Managing risk in hazardous conditions: improvisation is not enough. BMJ Qual Saf. 2020;29(1):60-63. doi:10.1136/bmjqs-2019-009443. https://psnet.ahrq.gov/issue/managing-risk-hazardous-conditions-improvisation… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38046/psn-pdfSeptember 10, 2008 - Clinical and pathological disagreement upon the cause of death in a teaching hospital: analysis of 100 autopsy cases in a prospective study. September 10, 2008 Pinto Carvalho FL, Cordeiro JA, Cury PM. Clinical and pathological disagreement upon the cause of death in a teaching hospital: Analysis of 100 autopsy cas… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46651/psn-pdfJanuary 17, 2018 - Piloting a patient safety and quality improvement co- curriculum. January 17, 2018 Kroker-Bode C, Whicker SA, Pline ER, et al. Piloting a patient safety and quality improvement co- curriculum. J Community Hosp Intern Med Perspect. 2017;7(6):351-357. doi:10.1080/20009666.2017.1403830. https://psnet.ahrq.gov/issue/… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46389/psn-pdfNovember 15, 2017 - Creating a highly reliable neonatal intensive care unit through safer systems of care. November 15, 2017 Panagos PG, Pearlman SA. Creating a Highly Reliable Neonatal Intensive Care Unit Through Safer Systems of Care. Clin Perinatol. 2017;44(3):645-662. doi:10.1016/j.clp.2017.05.006. https://psnet.ahrq.gov/issue/cr… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/844554/psn-pdfFebruary 15, 2023 - Medication mix-up: what happened at Vanderbilt and how it impacts health care providers. February 15, 2023 Michel C, Talley C. J Health Life Sci Law. 2022;17(1):71 https://psnet.ahrq.gov/issue/medication-mix-what-happened-vanderbilt-and-how-it-impacts-health-care- providers High-profile medication errors like tha… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43294/psn-pdfApril 25, 2016 - The right and wrong way to talk to patients about adverse events. April 25, 2016 Beaulieu-Volk D. The right and wrong way to talk to patients about adverse events. Medical economics. 2014;91(11):52-5. https://psnet.ahrq.gov/issue/right-and-wrong-way-talk-patients-about-adverse-events Apology laws have been explor… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/861294/psn-pdfJanuary 24, 2024 - Shining a glaring light on surgery: technology that records every move aims to improve safety. January 24, 2024 Freyer FJ. Boston Globe. January 13, 2024. https://psnet.ahrq.gov/issue/shining-glaring-light-surgery-technology-records-every-move-aims-improve- safety The surgical black box uses cameras and microphon…
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