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2541. Serious Safety Events: Getting to Zero. Second Edition. | PSNet
      psnet.ahrq.gov/issue/serious-safety-events-getting-zero-second-edition
      February 19, 2014 - Book/Report Serious Safety Events: Getting to Zero. Second Edition. Citation Text: Serious Safety Events: Getting to Zero. Second Edition. Hoppes M, Mitchell JL. Chicago, IL: American Society for Healthcare Risk Management; October 2014. Copy Citation Save Save to…

2542. Root Cause Analysis Playbook. | PSNet
      psnet.ahrq.gov/issue/root-cause-analysis-playbook
      July 05, 2017 - Book/Report Root Cause Analysis Playbook. Citation Text: Root Cause Analysis Playbook. Chicago, IL: American Society for Healthcare Risk Management; 2015. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter…

2543. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60826/psn-pdf
      August 19, 2020 - Variation in electronic test results management and its implications for patient safety: a multisite investigation. August 19, 2020 Thomas J, Dahm MR, Li J, et al. Variation in electronic test results management and its implications for patient safety: a multisite investigation. J Am Med Inform Assoc. 2020;27(8):12…

2544. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60986/psn-pdf
      January 01, 2021 - Organisational crisis resource management: leading an academic department of emergency medicine through the COVID-19 pandemic. October 7, 2020 Gavin N, Romney M-LS, Lema PC, et al. Organisational crisis resource management: leading an academic department of emergency medicine through the COVID-19 pandemic. BMJ Lea…

2545. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46824/psn-pdf
      June 26, 2018 - Management reasoning: beyond the diagnosis. June 26, 2018 Cook DA, Sherbino J, Durning SJ. Management Reasoning: Beyond the Diagnosis. JAMA. 2018;319(22):2267-2268. doi:10.1001/jama.2018.4385. https://psnet.ahrq.gov/issue/management-reasoning-beyond-diagnosis This commentary reviews five differences between diagno…

2546. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843051/psn-pdf
      February 01, 2023 - Describe the signs of cervical hematoma in the early postoperative period Understand the approaches for managing

2547. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36294/psn-pdf
      July 14, 2010 - Care management implementation and patient safety. July 14, 2010 Alexander JA; Weiner BJ; Baker LC; et al. J Patient Saf. 2006;2(2):83-96. https://psnet.ahrq.gov/issue/care-management-implementation-and-patient-safety The Institute of Medicine's Crossing the Quality Chasm report endorsed care management, defined as…

2548. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73709/psn-pdf
      September 15, 2021 - Crisis management for surgical teams and their leaders, lessons from the COVID-19 pandemic; a structured approach to developing resilience or natural organisational responses. September 15, 2021 Pring ET, Malietzis G, Kendall SWH, et al. Crisis management for surgical teams and their leaders, lessons from the COV…

2549. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838075/psn-pdf
      September 14, 2022 - Crisis recovery in surgery: error management and problem solving in safety-critical situations. September 14, 2022 Gogalniceanu P, Kunduzi B, Ruckley C, et al. Crisis recovery in surgery: error management and problem solving in safety-critical situations. Surgery. 2022;172(2):537-545. doi:10.1016/j.surg.2022.03.007…

2550. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854381/psn-pdf
      October 11, 2023 - Addressing bias in acute postoperative pain management. October 11, 2023 Harbell MW, Maloney J, Anderson MA, et al. Addressing bias in acute postoperative pain management. Curr Pain Headache Rep. 2023;27(9):407-415. doi:10.1007/s11916-023-01135-0. https://psnet.ahrq.gov/issue/addressing-bias-acute-postoperative-pa…

2551. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45574/psn-pdf
      November 23, 2016 - Patient safety events in out-of-hospital paediatric airway management: a medical record review by the CSI-EMS. November 23, 2016 Hansen M, Meckler G, Lambert W, et al. Patient safety events in out-of-hospital paediatric airway management: a medical record review by the CSI-EMS. BMJ Open. 2016;6(11):e012259. doi:10…

2552. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/862983/psn-pdf
      February 28, 2024 - Good communication between team members is vital when diagnosing and managing an operative emergency

2553. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44678/psn-pdf
      July 05, 2017 - Patient Safety Risk Management Playbook. July 5, 2017 Chicago, IL: American Society for Healthcare Risk Management; 2015. https://psnet.ahrq.gov/issue/patient-safety-risk-management-playbook Proactive risk management is an important component to improving the safety of care. Exploring principles of high reliabilit…

2554. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842772/psn-pdf
      January 18, 2023 - Short- and long-term effects of an electronic medication management system on paediatric prescribing errors. January 18, 2023 Westbrook JI, Li L, Raban MZ, et al. Short- and long-term effects of an electronic medication management system on paediatric prescribing errors. NPJ Digit Med. 2022;5(1):179. doi:10.1038/s4…

2555. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867226/psn-pdf
      December 04, 2024 - The nature of the response to airway management incident reports in high income countries: a scoping review. December 4, 2024 Endlich Y, Davies EL, Kelly J. The nature of the response to airway management incident reports in high income countries: a scoping review. Anaesth Intensive Care. 2024;52(5):283-301. doi:…

2556. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/764398/psn-pdf
      March 02, 2022 - What do we really know about crew resource management in healthcare?: An umbrella review on crew resource management and its effectiveness. March 2, 2022 Buljac-Samardzic M, Dekker-van Doorn CM, Maynard MT. What do we really know about crew resource management in healthcare?: An umbrella review on crew resource ma…

2557. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43013/psn-pdf
      March 12, 2014 - Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice. March 12, 2014 Bowie P, Halley L, McKay J. Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in gene…

2558. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/856638/psn-pdf
      November 29, 2023 - Safety Management Systems - an Introduction for Healthcare. November 29, 2023 Dorset, UK:  Health Services Safety Investigations Body; October 2023. https://psnet.ahrq.gov/issue/safety-management-systems-introduction-healthcare Safety management systems (SMS) are employed in many high-risk industries, yet are…

2559. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42109/psn-pdf
      March 13, 2013 - Nursing crew resource management: a follow-up report from the Veterans Health Administration. March 13, 2013 Sculli GL, Fore AM, West P, et al. Nursing crew resource management: a follow-up report from the Veterans Health Administration. J Nurs Adm. 2013;43(3):122-6. doi:10.1097/NNA.0b013e318283dafa. https://psnet…

2560. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43218/psn-pdf
      July 28, 2014 - Risk management—learning from the mistakes of others. July 28, 2014 Meydan C. Risk management--learning from the mistakes of others. J Eval Clin Pract. 2014;20(4):505-7. doi:10.1111/jep.12165. https://psnet.ahrq.gov/issue/risk-management-learning-mistakes-others This commentary introduces a structured process for …