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5441. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72685/psn-pdf
      January 27, 2021 - Human Factors and Ergonomics in Healthcare. January 27, 2021 Carayon P, Hignett S, Albolino S eds. Int J Qual Health Care. 2021;33(Supp1):1-71.    https://psnet.ahrq.gov/issue/human-factors-and-ergonomics-healthcare Human factors approaches have been identified as one of the primary vehicles to create las…

5442. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60674/psn-pdf
      July 08, 2020 - Sway: Unravelling Unconscious Bias July 8, 2020 Agarwal P. London, UK: Bloomsbury Sigma; 2020. ISBN 9781472971357.  https://psnet.ahrq.gov/issue/sway-unravelling-unconscious-bias Implicit biases influence behavior and decision making. This publication discusses how a range of implicit biases affect legal…

5443. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46759/psn-pdf
      January 31, 2018 - Health Literacy Toolkit. January 31, 2018 Leeds, UK: Health Education England, Public Health England, NHS England and Community Health and Learning Foundation; December 11, 2017. https://psnet.ahrq.gov/issue/health-literacy-toolkit Limits in patients' ability to understand health instructions and information affec…

5444. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36432/psn-pdf
      December 22, 2010 - The 80-hour work guidelines and resident survey perceptions of quality. December 22, 2010 Biller K, Antonacci AC, Pelletier S, et al. The 80-hour work guidelines and resident survey perceptions of quality. J Surg Res. 2006;135(2):275-81. https://psnet.ahrq.gov/issue/80-hour-work-guidelines-and-resident-survey-perc…

5445. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48106/psn-pdf
      July 24, 2019 - Teamwork Toolkit. July 24, 2019 Durham, NC: Duke Center for Healthcare Safety and Quality; June 2019. https://psnet.ahrq.gov/issue/teamwork-toolkit Improving teamwork and communication is a continued focus in the hospital setting. This toolkit is designed to help organizations create a culture that embeds teamwork…

5446. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73898/psn-pdf
      September 29, 2021 - A Thematic Analysis of HSIB's First 22 Investigations.  September 29, 2021 Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021. https://psnet.ahrq.gov/issue/thematic-analysis-hsibs-first-22-investigations In-depth failure investigations provide improvement insights for individuals and or…

5447. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/839330/psn-pdf
      November 02, 2022 - Diagnosis: Reducing Errors and Improving Quality. November 2, 2022 Schiff G. Chapter In: Loscalzo J, Fauci A, Kasper D, et al, eds. Harrison's Principles of Internal Medicine, 21e. New York, NY: McGraw Hill; 2022 https://psnet.ahrq.gov/issue/diagnosis-reducing-errors-and-improving-quality The task of performing a …

5448. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46316/psn-pdf
      August 02, 2017 - Defending a "never event." August 2, 2017 Shepperd JR. Defending a "Never Event". J Healthc Risk Manag. 2017;37(1):17-22. doi:10.1002/jhrm.21277. https://psnet.ahrq.gov/issue/defending-never-event Surgical fires are considered a never event. This commentary provides an overview of surgical fires, explains element…

5449. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50578/psn-pdf
      October 23, 2019 - Implementing Patient Safety: Addressing Culture, Conditions and Values to Help People Work Safely. October 23, 2019 Woodward, S. 1st ed. New York, NY: Taylor & Francis Group; Sept 2019. ISBN: 9780815376859. https://psnet.ahrq.gov/issue/implementing-patient-safety-addressing-culture-conditions-and-values-help- peop…

5450. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38213/psn-pdf
      November 12, 2008 - AHRQ announces interest in research on diagnostic errors in ambulatory care settings. November 12, 2008 Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 25, 2007. Publication No. NOT-HS-08-002. https://psnet.ahrq.gov/issue/ahrq-announces-interest-research-diagnostic-error…

5451. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74167/psn-pdf
      December 08, 2021 - National Patient Safety Board Advocacy Coalition. December 8, 2021 EQT Plaza, 625 Liberty Ave, Ste. 2500, Pittsburgh, PA 15222. https://psnet.ahrq.gov/issue/national-patient-safety-board-advocacy-coalition Centralized reporting and analysis of adverse events in health care is a safety improvement model from the av…

5452. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/839328/psn-pdf
      November 02, 2022 - Quality and Safety. November 2, 2022 Iyer R, Walker A, eds. Paediatr Anaesth. 2022;32(11):1176-1272. https://psnet.ahrq.gov/issue/quality-and-safety-1 Progress made in the adoption of infrastructure, Safety I, and Safety II concepts in high- and middle- to lower-income countries around the world support safe pedia…

5453. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35550/psn-pdf
      March 02, 2010 - Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. March 2, 2010 Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. Sleep. 2005;28(11):1392-402. https://psnet.ahrq.gov/issue/sleep-loss-and-performance-residents-and-nonphysicians…

5454. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35495/psn-pdf
      February 22, 2010 - The Patient Safety Institute demonstration project: a model for implementing a local health information infrastructure. February 22, 2010 Classen D, Kanhouwa M, Will D, et al. The patient safety institute demonstration project: a model for implementing a local health information infrastructure. J Healthc Inf Manag…

5455. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50433/psn-pdf
      September 04, 2019 - In men, it's Parkinson's. In women, it's hysteria. September 4, 2019 Armstrong D. ProPublica. August 23, 2019. https://psnet.ahrq.gov/issue/men-its-parkinsons-women-its-hysteria Implicit biases can affect communication, diagnosis, and treatment decisions. This news article reports the experience of a neurologist a…

5456. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44206/psn-pdf
      December 16, 2015 - Your new medical team: algorithms and physicians. December 16, 2015 Frakt A. New York Times. December 7, 2015. https://psnet.ahrq.gov/issue/your-new-medical-team-algorithms-and-physicians Humans are vulnerable to distraction, fatigue, and memory lapses, which can hinder their ability to process information. This n…

5457. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39622/psn-pdf
      June 23, 2010 - Safety concerns of hospital-based new-to-practice registered nurses and their preceptors. June 23, 2010 Myers S, Reidy P, French B, et al. Safety concerns of hospital-based new-to-practice registered nurses and their preceptors. J Contin Educ Nurs. 2010;41(4):163-71. doi:10.3928/00220124-20100326-02. https://psnet…

5458. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35523/psn-pdf
      December 14, 2010 - ISMP Medication Errors Reporting Program. December 14, 2010 Institute for Safe Medication Practices https://psnet.ahrq.gov/issue/ismp-medication-errors-reporting-program The Institute for Safe Medication Practices (ISMP) administers this national reporting program, which collects confidential reports of medication…

5459. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43790/psn-pdf
      October 23, 2023 - Complaints to the Parliamentary and Health Service Ombudsman. October 23, 2023 Manchester, UK: Parliamentary and Health Service Ombudsman. https://psnet.ahrq.gov/issue/complaints-about-acute-trusts-2016-2017 The National Health Service broadly reports the results of system-level analyses and investigations into t…

5460. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74136/psn-pdf
      December 01, 2021 - Development and expression of a high-reliability organization. December 1, 2021 Phillips RA, Schwartz RL, Sostman HD, et al. Development and expression of a high-reliability organization. NEJM Catal Innov Care Deliv. 2021;2(12). doi:10.1056/cat.21.0314. https://psnet.ahrq.gov/issue/development-and-expression-high-…