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7161. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39039/psn-pdf
      October 21, 2009 - Quality of medication use in primary care—mapping the problem, working to a solution: a systematic review of the literature. October 21, 2009 Garfield S, Barber N, Walley P, et al. Quality of medication use in primary care--mapping the problem, working to a solution: a systematic review of the literature. BMC Med.…

7162. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34599/psn-pdf
      January 30, 2008 - Organizational Learning from Experience in High-Hazard Industries: Problem Investigations as Off-line Reflective Practice. January 30, 2008 Carroll JS, Rudolph JW, Hatakenaka S. Cambridge, MA: MIT Sloan School of Management; 2002. Working Paper 4359-02 https://psnet.ahrq.gov/issue/organizational-learning-experien…

7163. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50728/psn-pdf
      December 11, 2019 - Before mea culpa, Children’s was confident its air systems weren’t source of infection December 11, 2019 Gilbert D, Gutman D. Seattle Times. November 26, 2019. https://psnet.ahrq.gov/issue/mea-culpa-childrens-was-confident-its-air-systems-werent-source-infection Problems in the physical environment can contribute …

7164. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46333/psn-pdf
      June 25, 2018 - High reliability leadership: a conceptual framework. June 25, 2018 Martínez-Córcoles M. High reliability leadership: A conceptual framework. J Contingencies Crisis Manage. 2017;26(2):237-246. doi:10.1111/1468-5973.12187. https://psnet.ahrq.gov/issue/high-reliability-leadership-conceptual-framework Leadership engag…

7165. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47320/psn-pdf
      September 05, 2018 - Patient safety climate: a study of Southern California healthcare organizations. September 5, 2018 Avramchuk AS, McGuire SJJ. Patient Safety Climate: A Study of Southern California Healthcare Organizations. J Healthc Manag. 2018;63(3):175-192. doi:10.1097/JHM-D-16-00004. https://psnet.ahrq.gov/issue/patient-safety…

7166. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42056/psn-pdf
      January 01, 2014 - Antecedents of willingness to report medical treatment errors in health care organizations: a multilevel theoretical framework. December 18, 2013 Naveh E, Katz-Navon T. Antecedents of willingness to report medical treatment errors in health care organizations: a multilevel theoretical framework. Health Care Manage…

7167. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46730/psn-pdf
      May 03, 2018 - Physician gender and apologies in clinical interactions. May 3, 2018 Hill KM, Blanch-Hartigan D. Physician gender and apologies in clinical interactions. Patient Educ Couns. 2018;101(5):836-842. doi:10.1016/j.pec.2017.12.005. https://psnet.ahrq.gov/issue/physician-gender-and-apologies-clinical-interactions This si…

7168. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47052/psn-pdf
      July 31, 2018 - The risks to patient safety from health system expansions. July 31, 2018 Haas S, Gawande AA, Reynolds ME. The Risks to Patient Safety From Health System Expansions. JAMA. 2018;319(17):1765-1766. doi:10.1001/jama.2018.2074. https://psnet.ahrq.gov/issue/risks-patient-safety-health-system-expansions Changes in organ…

7169. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39567/psn-pdf
      May 18, 2016 - Effectiveness of interventions designed to promote patient involvement to enhance safety: a systematic review. May 18, 2016 Hall J, Peat M, Birks Y, et al. Effectiveness of interventions designed to promote patient involvement to enhance safety: a systematic review. Qual Saf Health Care. 2010;19(5):e10. doi:10.11…

7170. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47795/psn-pdf
      February 20, 2019 - Three laws for paperlessness. February 20, 2019 Thimbleby H. Three laws for paperlessness. Digit Health. 2019;5:2055207619827722. doi:10.1177/2055207619827722. https://psnet.ahrq.gov/issue/three-laws-paperlessness The digitization of health care data has had some positive effects on patient safety, but it has also…

7171. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46520/psn-pdf
      December 19, 2017 - The emotional fallout from the culture of blame and shame. December 19, 2017 Ferguson CC. The emotional fallout from the culture of blame and shame. JAMA Pediatr. 2017;171(12):1141. doi:10.1001/jamapediatrics.2017.2691. https://psnet.ahrq.gov/issue/emotional-fallout-culture-blame-and-shame In this commentary, a p…

7172. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851059/psn-pdf
      June 28, 2023 - Causes for medical errors in obstetrics and gynaecology. June 28, 2023 Klemann D, Rijkx M, Mertens H, et al. Causes for medical errors in obstetrics and gynaecology. Healthcare (Basel). 2023;11(11):1636. doi:10.3390/healthcare11111636. https://psnet.ahrq.gov/issue/causes-medical-errors-obstetrics-and-gynaecology R…

7173. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44998/psn-pdf
      April 20, 2016 - High reliability: excellent care every time. April 20, 2016 Saver C. High reliability: Excellent care every time. OR manager. 2016;32(3):22-6. https://psnet.ahrq.gov/issue/high-reliability-excellent-care-every-time Achieving high reliability has attracted attention as a goal in health care. This article provides an…

7174. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866520/psn-pdf
      August 14, 2024 - People are more error-prone after committing an error. August 14, 2024 Adkins TJ, Zhang H, Lee TG. People are more error-prone after committing an error. Nat Commun. 2024;15(1):6422. doi:10.1038/s41467-024-50547-y. https://psnet.ahrq.gov/issue/people-are-more-error-prone-after-committing-error In order to improve …

7175. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44152/psn-pdf
      November 06, 2015 - Infection Prevention. November 6, 2015 Allen G, ed. AORN J. 2015;101:505-596. https://psnet.ahrq.gov/issue/infection-prevention A primary concern in the perioperative setting is the prevention of health care–associated infections, particularly surgical site infections. Articles in this special issue explore strate…

7176. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43879/psn-pdf
      February 04, 2015 - Complaints and Raising Concerns. February 4, 2015 Fourth Report of Session 2014–15. House of Commons Health Committee. London, England: The Stationery Office; January 13, 2015. Publication HC 350. https://psnet.ahrq.gov/issue/complaints-and-raising-concerns Complaints are a proactive way to monitor and address rec…

7177. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42985/psn-pdf
      February 26, 2014 - Confusion—specimen mix-up in dermatopathology and measures to prevent and detect it. February 26, 2014 Weyers W. Confusion-specimen mix-up in dermatopathology and measures to prevent and detect it. Dermatol Pract Concept. 2014;4(1):27-42. doi:10.5826/dpc.0401a04. https://psnet.ahrq.gov/issue/confusion-specimen-mix…

7178. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47084/psn-pdf
      July 25, 2018 - Best Practices for Safe Medication Administration During Anesthesia Care. July 25, 2018 APSF Committee on Technology. Anesthesia Patient Safety Foundation. https://psnet.ahrq.gov/issue/best-practices-safe-medication-administration-during-anesthesia-care Medication errors in anesthesia practice can be result in ser…

7179. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36635/psn-pdf
      January 14, 2011 - Six steps from head to hand: a simulator based transfer oriented psychological training to improve patient safety. January 14, 2011 Müller MP, Hänsel M, Stehr SN, et al. Six steps from head to hand: a simulator based transfer oriented psychological training to improve patient safety. Resuscitation. 2007;73(1):137-4…

7180. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40716/psn-pdf
      March 22, 2017 - Promoting Safety and Quality Through Human Resource Practices: Executive Summary. March 22, 2017 McAlearney AS, Song P, Garman A, McHugh M, Caputo N. Rockville, MD: Agency for Healthcare Research and Quality; August 2011. AHRQ Publication No. 11-0080-EF. https://psnet.ahrq.gov/issue/promoting-safety-and-quality-th…