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6401. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36219/psn-pdf
      October 18, 2010 - Risk, society and system failure. October 18, 2010 Scalliet P. Risk, society and system failure. Radiotherapy and Oncology. 2006;80(3). doi:10.1016/j.radonc.2006.07.003. https://psnet.ahrq.gov/issue/risk-society-and-system-failure The author discusses why large scale accidents happen and how to manage risk in radi…

6402. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40466/psn-pdf
      May 18, 2011 - Making FMEA work for you. May 18, 2011 Reams J. Making FMEA work for you. Nurs Manage. 2011;42(5):18-20. doi:10.1097/01.NUMA.0000396500.05462.6e. https://psnet.ahrq.gov/issue/making-fmea-work-you This commentary describes failure mode and effects analysis and discusses how it can improve patient safety. https://…

6403. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37381/psn-pdf
      March 28, 2012 - Hospital safety records, CEO pay increasingly linked. March 28, 2012 Wilson B. American Medical News: November 26, 2007. https://psnet.ahrq.gov/issue/hospital-safety-records-ceo-pay-increasingly-linked This article explores the recent trend of hospitals tying senior management compensation and incentives to mortal…

6404. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40047/psn-pdf
      December 01, 2010 - Positive Working Relationships Matter for Better Nurse and Patient Outcomes. December 1, 2010 Spence Laschinger HK, ed. J Nurs Manag. 2010;18(8):875-1086 https://psnet.ahrq.gov/issue/positive-working-relationships-matter-better-nurse-and-patient-outcomes This special issue explores workplace relationships and thei…

6405. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37111/psn-pdf
      January 01, 2023 - Patient Safety: An Old and New Issue. August 22, 2007 Bagnara S; Tartaglia R, eds. Theor Issues Ergon Sci. 2023;8(5):365-507. https://psnet.ahrq.gov/issue/patient-safety-old-and-new-issue This special issue contains articles focusing on ergonomic research areas that intersect with patient safety, such as team mana…

6406. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36869/psn-pdf
      August 31, 2011 - An extra dose of safety. August 31, 2011 An extra dose of safety. Installation of a bar-coding system drives an entire workflow redesign at a non- profit hospital and healthcare network. Health management technology. 2007;28(4):30-2, 34. https://psnet.ahrq.gov/issue/extra-dose-safety This article describes a healt…

6407. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37037/psn-pdf
      September 16, 2011 - Getting beyond blame in your practice. September 16, 2011 Pawar M. Getting beyond blame in your practice. Family Practice Management. 2007;14(5):30-34. https://psnet.ahrq.gov/issue/getting-beyond-blame-your-practice The author discusses how to develop core competencies to help teams create a blame-free culture that…

6408. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38810/psn-pdf
      July 22, 2009 - When doctors make mistakes. July 22, 2009 Chen PW. https://psnet.ahrq.gov/issue/when-doctors-make-mistakes-1 This column shares one physician's experience with the deterioration of a colleague's practice after involvement in error. The piece highlights the need for effective support of physicians-in-training to ma…

6409. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40607/psn-pdf
      July 13, 2011 - Biomedical Complexity and Error. July 13, 2011 Patel VL, Kahol K, Buchman T, eds. J Biomed Inform. 2011;44:385-506.    https://psnet.ahrq.gov/issue/biomedical-complexity-and-error This special issue explores complexity in error management, clinical workflow, and decision making. https://psnet.ahrq.gov/is…

6410. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38648/psn-pdf
      May 27, 2009 - Piecing together medication administration. May 27, 2009 Anderson HJ. Health Data Management. May 1, 2009;17:22. https://psnet.ahrq.gov/issue/piecing-together-medication-administration This article discusses efforts to support medicine administration through various information technology techniques. It is second …

6411. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36899/psn-pdf
      April 12, 2011 - The role of communication in paediatric drug safety. April 12, 2011 Stebbing C, Wong ICK, Kaushal R, et al. The role of communication in paediatric drug safety. Arch Dis Child. 2007;92(5):440-5. https://psnet.ahrq.gov/issue/role-communication-paediatric-drug-safety The authors review the literature on how communic…

6412. A Laceration that Needed a Proper Exam, Not an X-Ray | PSNet
      psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
      November 25, 2020 - SPOTLIGHT CASE A Laceration that Needed a Proper Exam, Not an X-Ray Citation Text: Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Cit…

6413. In Conversation With… Mark Chassin, MD, MPP, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
      April 26, 2023 - In Conversation With… Mark Chassin, MD, MPP, MPH April 1, 2017  Citation Text: In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Cit…

6414. Unseen Perils of Urinary Catheters | PSNet
      psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
      January 31, 2024 - Unseen Perils of Urinary Catheters Citation Text: Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar Bib…

6415. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73153/psn-pdf
      April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough April 28, 2021 Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough Disclosure of Relev…

6416. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73398/psn-pdf
      June 30, 2021 - In Conversation With... Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA June 30, 2021 In Conversation With.. Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia- …

6417. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35004/psn-pdf
      May 18, 2005 - Lean Six Sigma reduces medication errors. May 18, 2005 Esimai G. Quality Progress; 2005;38(4):51-57. https://psnet.ahrq.gov/issue/lean-six-sigma-reduces-medication-errors The authors analyze one hospital’s quality management program. Using a Six Sigma methodology, the program identified policy and practice changes…

6418. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39538/psn-pdf
      May 19, 2010 - CPOE: strategies for success. May 19, 2010 Manor PJ. CPOE: Strategies for success. Nurs Manage. 2010;41(5):18-20. doi:10.1097/01.NUMA.0000372028.99240.7f. https://psnet.ahrq.gov/issue/cpoe-strategies-success This commentary reviews tactics to engage nurses in computerized provider order entry (CPOE) implementatio…

6419. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40687/psn-pdf
      September 03, 2011 - HIM functions in healthcare quality and patient safety. September 3, 2011 Berretoni A, Bochantin F, Brown T, et al. HIM functions in healthcare quality and patient safety. J AHIMA. 2011;82(8):42-5. https://psnet.ahrq.gov/issue/him-functions-healthcare-quality-and-patient-safety This piece discusses the role of hea…

6420. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35543/psn-pdf
      June 12, 2013 - Health care safety: what needs to be done? June 12, 2013 Rubin GL, Leeder SR. Health care safety: what needs to be done? Med J Aust. 2005;183(10):529-31. https://psnet.ahrq.gov/issue/health-care-safety-what-needs-be-done The authors assert that enhancements in measuring safety, financial incentives, education, and …