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6121. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44397/psn-pdf
      September 30, 2015 - Incidence- versus prevalence-based measures of inappropriate prescribing in the Veterans Health Administration. September 30, 2015 Lund BC, Carrel M, Gellad WF, et al. Incidence- Versus Prevalence-Based Measures of Inappropriate Prescribing in the Veterans Health Administration. J Am Geriatr Soc. 2015;63(8):1601-7…

6122. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/856637/psn-pdf
      November 29, 2023 - Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow- Up Care at the Phoenix VA Health Care System in Arizona. November 29, 2023 Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07. https://psnet.ahrq.gov/issue/deficiencies-…

6123. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60225/psn-pdf
      April 15, 2020 - Beyond 'find and fix': improving quality and safety through resilient healthcare systems. April 15, 2020 Anderson JE, Ross AJ, Back J, et al. Beyond ‘find and fix’: improving quality and safety through resilient healthcare systems. Int J Qual Health Care. 2020;32(3):204-211. doi:10.1093/intqhc/mzaa007. https://psn…

6124. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838926/psn-pdf
      October 26, 2022 - Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error. October 26, 2022 Cooper J, Thomas BJ, Rebello E, et al for the APSF Criminalization of Error Task Force. APSF Newsletter. October 2022; 37(3):80-81 https://psnet.ahrq.gov/issue/position-statement-cri…

6125. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73924/psn-pdf
      October 06, 2021 - Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings. October 6, 2021 Weenink J-W, Wallenburg I, Leistikow I, et al. Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and…

6126. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45622/psn-pdf
      December 07, 2016 - National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. December 7, 2016 D'Alton ME, Friedman AM, Smiley RM, et al. National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. J Obstet Gynecol Neonatal Nurs. 2016;45(5):706-717. doi:10.1016/j.jogn.2016.07.001.…

6127. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73138/psn-pdf
      April 14, 2021 - An act of performance: exploring residents' decision- making processes to seek help. April 14, 2021 Jansen I, Stalmeijer RE, Silkens MEWM, et al. An act of performance: exploring residents’ decision? making processes to seek help. Med Educ. 2021;55(6):758-767. doi:10.1111/medu.14465. https://psnet.ahrq.gov/issue/a…

6128. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50686/psn-pdf
      January 01, 2020 - 'Whatever you cut, I can fix it': clinical supervisors' interview accounts of allowing trainee failure while guarding patient safety. November 20, 2019 Klasen JM, Driessen E, Teunissen PW, et al. ‘Whatever you cut, I can fix it’: clinical supervisors’ interview accounts of allowing trainee failure while guarding p…

6129. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47263/psn-pdf
      January 01, 2021 - Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety. November 28, 2018 Guttman OT, Lazzara EH, Keebler JR, et al. Dissecting Communication Barriers in Healthcare: A Path to Enhancing Communication Resiliency, Reliability, and Patient Safety…

6130. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45098/psn-pdf
      May 04, 2016 - Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report. May 4, 2016 The Clinical Center Working Group Report to the Advisory Committee to the Director, National Institutes of Health. Bethesda, MD; National Institutes of Health; April 2016. https://psnet.ahrq.gov/issue/reducing…

6131. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45292/psn-pdf
      September 07, 2016 - Electronic approaches to making sense of the text in the adverse event reporting system. September 7, 2016 Benin AL, Fodeh SJ, Lee K, et al. Electronic approaches to making sense of the text in the adverse event reporting system. J Healthc Risk Manag. 2016;36(2):10-20. doi:10.1002/jhrm.21237. https://psnet.ahrq.go…

6132. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47298/psn-pdf
      September 24, 2018 - Physician engagement in malpractice risk reduction: a UPHS case study. September 24, 2018 Diraviam SP, Sullivan P, Sestito JA, et al. Physician Engagement in Malpractice Risk Reduction: A UPHS Case Study. Jt Comm J Qual Patient Saf. 2018;44(10):605-612. doi:10.1016/j.jcjq.2018.03.009. https://psnet.ahrq.gov/issue/…

6133. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46273/psn-pdf
      August 30, 2017 - Increasing patient safety with neonates via handoff communication during delivery: a call for interprofessional health care team training across GME and CME. August 30, 2017 Vanderbilt AA, Pappada SM, Stein H, et al. Increasing patient safety with neonates via handoff communication during delivery: a call for int…

6134. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60334/psn-pdf
      May 13, 2020 - Crisis Standards of Care: Ten Years of Successes and Challenges–Proceedings of a Workshop. May 13, 2020 National Academies of Sciences, Engineering, and Medicine. Washington, DC; The National Academies Press: 2020. ISBN 9780309676250. https://psnet.ahrq.gov/issue/crisis-standards-care-ten-years-successes-and-…

6135. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866694/psn-pdf
      September 11, 2024 - What's the harm? Results of an active surveillance adverse event reporting system for chiropractors and physiotherapists. September 11, 2024 Pohlman KA, Funabashi M, O’Beirne M, et al. What’s the harm? Results of an active surveillance adverse event reporting system for chiropractors and physiotherapists. PLoS ONE…

6136. Hindsight Bias | PSNet
      psnet.ahrq.gov/glossary/hindsight-bias
      September 13, 2021 - Hindsight Bias September 13, 2021 Anonymous (not verified) In a very general sense, hindsight bias relates to the common expression "hindsight is 20/20." This expression captures the tendency for people to regard past events as expected or obvious, even when, in real time, the events perplexed those involved. M…

6137. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/862152/psn-pdf
      February 07, 2024 - Risk identification and prediction of complaints and misconduct against health practitioners: a scoping review. February 7, 2024 Wang Y, Ram SS, Scahill S. Risk identification and prediction of complaints and misconduct against health practitioners: a scoping review. Int J Qual Health Care. 2024;36(1):mzad114. doi…

6138. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36698/psn-pdf
      February 24, 2011 - The impact of duty hours on resident self reports of errors. February 24, 2011 Vidyarthi A, Auerbach AD, Wachter R, et al. The impact of duty hours on resident self reports of errors. J Gen Intern Med. 2007;22(2):205-9. https://psnet.ahrq.gov/issue/impact-duty-hours-resident-self-reports-errors Residency programs…

6139. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72722/psn-pdf
      February 10, 2021 - Knowledge, attitudes, and expectations of medical staff toward medical error management policies in humanitarian medicine: a qualitative study. February 10, 2021 Biquet J-M, Schopper D, Sprumont D, et al. Knowledge, attitudes, and Expectations of Medical Staff Toward Medical Error Management Policies in Humanitari…

6140. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42252/psn-pdf
      May 08, 2013 - Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors. May 8, 2013 Panesar S, Carson-Stevens A, Salvilla SA, et al. Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an …